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Medical Profession and Charity:  A Guideline For Medical Students (Speech at a recent Medical Event)

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© Dr. Rajas Deshpande

My dear friends, you will receive many sermons about your responsibility to do charity and social service from those who do no charity themselves. Many who have never done anything worthwhile for the society will remind you of your Hippocratic oath. Beware of these distractors, your social service and charity is your own choice. Thousands of doctors who chose to settle down in the remote place, purely with an intention to serve people, and carried on general practice for over 50 years are now dependent upon someone helping them for their own medical treatment. Neither the government, nor those whom we help reciprocate. Those who lecture doctors about serving the society never answer this simple question: what if a doctor serving the society very well, needs help? Who will help him? The answer is clear. First safeguard your career, reputation, family, home, parents, future and then do charity like a king, confidently, freely and with pride. Professional goals are not the same for everyone.
Some base the entire concept of charity on the low fees, without any analysis of the quality of medical care provided and the outcomes. A patient treated free but wrong, a patient treated at a low cost with a poor outcome cannot be considered charity. “Self-Declaration” of numbers of such patients treated without an analysis of outcomes and patient feedback is nothing but cheap hidden advertisements.
All of us don’t come from the same background: Some families have lived in perpetual poverty, selling off land and compromising quality of housing, clothes and even food to send their children through the medical education. Some must repay their loans, some must attend too many family duties and some just struggle to survive with a middleclass lifestyle. The first thing that we must overcome while doing any charity or social service is the feeling that those who are unable to do it are somehow lesser to us. That discrimination must go. A doctor doing his / her job well is enough charity, they have sacrificed their youth for the society. © Dr. Rajas Deshpande
Let us look at the career options most Indian doctors have.
Medical teachers have already accepted a very low salary compared to what they truly deserve, The average salary of a medical professor in USA and UK exceeds INR 8 lacs per month, working 8 AM-4 PM, with one emergency per week. Although I do not contribute to the school of thought that one must accept the low Indian financial status, at one-fourth salary per month, our medical teachers work three times more than the doctors in the developed world (because in India the staff is never filled adequately) . Still they continue to put in their blood and sweat, training thousands of medical students, working almost 24/7, seeing far more number of patients in OPD, IPD and Emergency. This is the best possible medical social service, nay, charity being done in India, let me first respect and salute this unrecognized social service. This is an ideal premise for those who want to continue to be available for the poor masses, keep themselves abreast of the most modern medical knowledge, and impart it to the meritorious future generations of doctors.
A similar career is working as medical officers in rural / semi-rural areas, where doctors are most deficient. In most Medical Institutes run by the government or municipal corporations, sycophancy and suppression , hopeless bosses, poor administration and heavy paperwork, punishment transfers and bribery are huge limitations for those who want to honestly serve patients. Life isn’t easy in rural surroundings. Right from the lack of basic amenities like water, electricity, good schooling and transport, to a severe threat to personal security by the rampant Political Gunda culture in a superstitious, orthodox community. Who will want to voluntarily expose their family to these? However, if one does have a social standing in one’s homeland, it becomes an excellent option to serve the society. © Dr. Rajas Deshpande
Coming to the non-government career options in medicine, one is either left to private practice as an individual practitioner, which offers a lot of freedom but limited resources, or a salaried practitioner at a corporate hospital.
In the corporate hospital culture, individual charity and social service becomes almost impossible. Contrary to the image created by the media, most of the corporate hospitals actually comply with the mandatory charity, worth crores of rupees every month to those BPL, but the need of our society is far more than that, the demands are never ending. The new doctor who wants to earn a good name and income, but also wants to do something worthwhile for the society as a free service, the corporate culture offers two options: a low-salaried position for looking after the mandatory charity, or working in their low input peripheral schemes. For a beginner, especially a specialist, these are both excellent options . © Dr. Rajas Deshpande
Coming to the last option: an individual private practitioner, there are many choices but also a stark reality: you are on your own, and on the day that you don’t earn, no one else pays for your innumerable bills. Remember that when you are an independent medical practitioner, you have zero income every day that you don’t work, so a single illness or problem that keeps you home for a month will bring your bank balance to zero. Unless there is an alternative source of income, which is rarely the case with a doctor, this jeopardizes your whole existence. You may be prepared to walk through this, but you will be doing your family a great injustice if you push them into this fate. Look at those who have done the greatest charity upon earth: Bill Gates, JK Rowling etc. They have first earned, secured themselves and their dependents and then returned in plenty to the world. That is the safest way to serve the society effectively and for long.
I know almost everyone in this hall is eager to help the downtrodden, poor and helpless. But there are some things you must first thrash out for yourself. Firstly, do not feel any obligation to copy charity. You can discover your own new ways to serve the needy. Completely ignore those who tell you what should be your financial worth. Once you decide what lifestyle you want, you can chart out how much percentage of your time you can work for charity. You may want to reserve one hour a day or one day every week. Be comfortable, choose what does not become a stress factor, but please stick to whatever you decide.
One hour a day by an Indian doctor means 4-5 free patients a day, that is 30 patients a week, that is 120 patients per month, and 1440 per year. If one consultation is 300 rupees, this way you are giving 4 lac 32 thousand rupees worth service free to the society.
There is a major problem : those who take advantage of free medical service. There already are many affording patients whom most doctors voluntarily see free: relatives, teachers, other doctors and their family, classmates, staff in their hospitals, maids and servants, watchmen, neighbors etc.. There are also others who demand free consultations: administrators, politicos, local heavyweights, ministers and even top businessmen who our bosses accompany. People often say that free service does not have any value, it is not respected, but I will make a small exception here: I feel that the really poor and helpless genuinely respect your free service, remember it for life and place you near God. It is the affluent who are usually thankless for free services, and it is high time that we should stop serving them free, so that we are able to serve the really deserving ones. © Dr. Rajas Deshpande
False poverty/ income certificates, visiting repeatedly for trivial / tiny complaints, daily questioning, become a huge limitation in extending free services openly. Pune teaches you many tricks to identify and deal with such people.
An equal legal responsibility for even the free patients is the law, and a major limiting factor for private practitioners as well as corporates. However careful one may be, every doctor does commit mistakes, and our courts of law are yet unevolved medically, only rare judges are mature enough to understand the intricacies of medical decision making and still rarer doctors understand the law. Look at the big picture: a doctor is treating a poor patient as charity, and unfortunately something goes wrong. The instant conclusion that it was the doctor’s mistake, the sensational news story that follows, and the threat to personal reputation all come to play together. The chance of “Extracting” money from the hospital or the doctor, in case of any complication or death, is considered a lucrative opportunity by many local goons.
A poor young lady with a stroke presented to my free OPD. I found her to have a valvular heart disease with a clot in the heart. We arranged for her free treatment, the best cardiac team in the city operated her free, for a major valve replacement open heart surgery. Everything including all complications was explained, poof on paper. In a month, she developed valve failure, a rare but known complication. The relatives returned with a gang of goons, threatened us in the OPD with dire consequences and legal action. The very family which begged for concessions with folded hands a month ago now spoke of vandalizing the hospital, beating us up. We explained to the patient and family that this is not a surgical mistake, that this is a rare but known complication, and it was still possible to correct it. Fortunately for us, the patient herself agreed for a redo surgery. The cardiac team operated her again, free, and the patient went home walking in a few days, but no one from the family ever expressed any gratitude. We had learnt a precious lesson: do not risk your career for charity or social service, because medical degrees, once cancelled or suspended are almost impossible to get back. © Dr. Rajas Deshpande
My friends, the real richness is that of the soul, and by becoming a Doctor you have already proven all that you need to prove about your soul. Whatever I must earn, I must proudly earn without causing hurt or having to deceive anyone. And believe me, Lord has provided enough for me always. Yes, there was a time when I sat in my hostel room and sung that song “Chaand Taare Ttod Laoon” from Yes Boss . Over the years, the kind Lord has responded to most of my prayers. There is no other profession in which you have such huge opportunity: your charity and service will bring people health and life: so use it freely, every day, always. Just make sure to protect yourself to help others for decades to come, and to pass on this light to the future generations.
Jai Hind!
© Dr. Rajas Deshpande
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The Nightmare

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“Wake Up! Wake Up!!!” shouted the wife frantically. The husband did not respond.
We told her to remain calm.
“How can you tell me to remain calm, doctor? Are you insane? Do something.. he is dying. What will I do without him? I have a two small kids… I beg of you, doctor! Here, I touch your feet! Please save my husband!” the lady kept shouting, panic-struck.

Her husband was riding a bike with a friend just an hour ago, and was dashed by a high-speed truck. The friend had died on the spot, and this gentleman had suffered a head trauma, with fractures in the bones of one hand and both legs. He was unconscious since admission. We had sutured his wounds, the bleeding was controlled, but he had already lost a lot of blood and his blood pressure was low. He was receiving blood transfusion now. © Dr. Rajas Deshpande

I was an intern then, at the civil hospital Nanded. Our Surgery medical officer had examined the patient, and suspected a bleeding in the skull / brain. There was no CT scan or Intensive care facility available, and the nearest city with a CT scan or ICU was Hyderabad, some seven hours away. The wife decided to shift him to Hyderabad. The MO told them that travel involved risks, the patient could worsen. He also suggested that he must not travel without an accompanying doctor.

“Please come with us” the wife requested me with folded hands. I convinced another intern friend to join me. That was at about midnight, the month was December. Very cold.

We prepared the emergency kit, including various injectables, tubes and Ambu bag required in case the breathing stops. We started in a basic “Ambulance”, with a reluctant driver motivated by the obvious. The night was as chilly and dark as it could be, the road bumpy and dusty, and the ambulance, except that there was a patient and two doctors in it, had nothing else to qualify as an ambulance. The only positive thing about it was its speed. © Dr. Rajas Deshpande

The patient mumbled something and became drowsy again. We requested the wife to please not be affected by such fluctuations, common in patients with head injury. We kept on measuring the blood pressure and pulse rate manually (there were no monitors then). We also kept a watch on his pupil size, as unequal pupils are a hint for swelling or bleeding in the brain. An hour into the journey, the patient had a convulsion. We had already given him an anticonvulsant, a standard protocol, but now we also had to give him diazepam to abort the fit. The fit stopped, but the blood pressure started dropping. We used steroid injections and increased the intravenous fluids. The use of diazepam may depress breathing, but we had no choice here. © Dr. Rajas Deshpande

The patient’s wife had bouts of extreme panic and kept weeping. Her suffering was justified, we tried not to let that affect our decisions. Two other relatives who accompanied her tried to console her. A doctor cannot run away from or avoid any situation, we were learning our lessons.

By 2 AM, the patient appeared relatively stable. The relatives slept off, the wife became silent, occasionally dozing off. I’m a nocturnal animal, but my friend was feeling very sleepy.

At about 3 AM, the ambulance suddenly stopped.
“I cannot drive anymore. I am tired and very sleepy. I need to have a tea and a smoke, otherwise I will fall asleep driving” the driver said. © Dr. Rajas Deshpande
There was no choice. We saw the small tea stall by the roadside. The relatives and patient’s wife had tea, my friend intern went out and had his cigarette and tea, then he sat with the patient while I had my smoke and tea. It was only after we started again that we realized how vital it was to have taken that break! The ambulance gained speed steadily.

An hour later, the patient became quite rowdy, and started to violently throw about his hands and legs, trying to get up. We tried to restrain him, but it became quite difficult, especially because the ambulance was running high speed, and the wife was now almost in a state of shock. We had to use diazepam again. His breathing became shallow, pulse rate started rising. We prepared for artificial ventilation.

As we approached the city by the dawn, the traffic increased, and we faced many blocks. We reached CDR Apollo hospital, just as we intubated the patient and started ventilating him with the Ambu bag. Dr. Raja Reddy, Neurosurgeon there, immediately attended the patient and himself accompanied us to the CT scan room. The scan showed some contusions / injuries to the brain, but no major bleeding. Dr. Reddy reassured the patient’s family, and praised the efforts we had made, being interns. Patient was taken to the ICU.

We returned by an ST bus the same afternoon, after thanking the ambulance driver. Few days later the patient was back on duty, completely recovered. One evening when I returned from the hospital, my parents showed me a beautiful thick gold necklace.

“That couple had come. They wanted to thank you, they gifted this for your son” my mother proudly said. Although my one month son did not know anything about gold, and I do not understand metallurgy well, my parents indeed had very proud smiles for the next few days. The glitter of those smiles is the only Gold I have preserved in life, like many doctors who go through this ordeal every day!
© Dr. Rajas Deshpande

Dedicated to hundreds of doctors who carry/ transfer patients in horrible situations / conditions, risking their own life, all across India.

PS: This is a story circa 1993, the management standards and guidelines, facilities have improved a lot today. Of Course smoking is a bad habit and not justified.
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Illegal Heroes

Illegal Heroes

© Dr. Rajas Deshpande

“I was at the disco last night. We danced a lot, I exceeded my ususal capacity of 180 ml alcohol, and had two or three large pegs extra. I must have smoked a little extra too yesterday, I was too stressed”’ said the 30 year old man, who was admitted one afternoon in an unconscious state. He had had a fit in the office that morning. The MRI had shown a large bleeding / haemorrhage in his brain. This illness, cerebral venous thrombosis, is quite common among those who are dehydrated, those who have untreated sinus infections, and among those who take contraceptive pills. If not treated in time, it can quickly cause brain swelling that may lead to disability or death.

Over next three days he gradually improved. Brain swelling started to recede, and he asked for a discharge. Faster and to-the-point care had improved his condition, thanks to modern healthcare. A psychiatrist had already counselled him about deaddiction. When we sent his file for discharge, his mediclaim insurance was declined because this illness was related to alcohol consumption. Immediately, his tone became bitter, his colleagues dissected the case papers asking for justification of each test, each medicine, and also why he was even hospitalised. Gratefulness is often waived off by doctors as a lost quality among saved patients, but it is difficult to tolerate arrogant distrust. We firmly explained him what was done and why.

“We will pay your bills, we will claim the insurance later, but you must change your notes, remove alcohol and smoking from his papers” said the patient’s brother.

“We cannot change the case notes, it is illegal. Also, we have already sent copies to the insurance company, a standard procedure. You are not obliging us by paying the bills, we have provided healthcare service that saved your brother, who was about to die due to alcohol consumption” we replied.

Within an hour, a local politician, an elected member, who came in his Range Rover with his personal armed bodyguards and human doggies, started his anti-medical show that had drama, emotion, tragedy, threats of violence and revenge and everything else but truth and honesty. He spoiled the day for everyone involved, caused disruption of hospital work for over six hours, and left with a threat of “burning down the hospital soon”. When our PRO asked him whether he wants to pay the bills of this patient to help them, his reaction was the hallmark of a true politician: change of topic to how the medical profession has lost its reputation.

Almost every doctor, every hospital in India is being threatened and pressurised by our own lawmakers at almost all levels into changing facts, writing false details, extorting concessions for the rich and poor both, only to increase their own vote banks at the cost of the healthcare industry. Most politicians, many government officers instead of financially helping the patient, ask the hospital to treat free or cut off bills.

How legal is this authority? If a politician writes to a court or lawyer or hotel or an Airline to waive off fees/ bills of a poor person, will they ever? Why are the doctor’s services and hospitals taken for granted here? How sad that such illegal means make pseudo-Heroes in our country!

Everytime the politicos pressurise a doctor or a hospital to treat their paying cronies free or concessional, some other truly deserving patient suffers because hospitals, small or big, can only do a certain level of charity. How fair is it to deny healthcare to the deserving poor just because they cannot flex a political muscle? This phenomenon is ruining the whole purpose and concept of charity healthcare measures all over India.

Aren’t these elected members responsible for the disgusting state of the civil and government hospitals and healthcare all over India? That is their domain of authority. This is like messing up one’s own home and family and requesting the one with a better home and family to pay and comply for one’s own needs. How shameful is it for the elected members of different parties to have to send people, especially the poor, to the private hospitals, because their own set-ups are failing perpetually? Empty posts, inadequate staff, poorest funding, non-availability of quality technology and medicines and red tapism have created massive monuments of the healthcare failures of different lawmakers all over India, and these are the very people who come threatening to the hospitals of burning them down! Hear this, any Milord?

If the honourable Prime Minister and Health Minister invite feedback from every patient leaving every civil and government hospital, the gravity of this situation will be understood better. Many repairs “at home” are required before “the neighbours home” is raided. We as doctors and hospitals must together request these authorities and offices to protect us from such daily insults, extortions and exploitation.

The very next day, an old man, a retired Indian Military officer, was expressing himself in the OPD with tears in his eyes: “Ye desh ka kuchh nahi honewala (This country cannot progress). People here, at all levels, want corruption, legal escapes to save money, and will elect anyone who throws them petty bits. Votes are bought for such favours as alcohol, gifts and cash. Sycophants rule, criminals are seen hand in hand with some rulers. Who do you think will get elected with such means, saints? You can guess what progress we expect if the lawmakers are first in line to break laws..”

There was nothing more sinister I heard that day. I am worried about the healthcare in my beloved country. God save the future generations from such illegal heroes!

© Dr. Rajas Deshpande

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To pause for respect

To pause for respect

To pause for respect

© Dr Rajas Deshpande

After completing the neurological examination, I asked Mr Harkishan Budhrani to sit down and put his shoes on. His son accompanying him got up, sat near his father’s feet and started to adjust his father’s shoes for comfort.

To pause for respect was my only choice.

Mr Harkishan Budhrani is a British citizen, and so are his sons Mr Naresh and Mr Raj. Every time one of them accompanies Mr. Budhrani for the consultation. They not only come prepared with their father’s health details, but also take notes and follow all the suggestions. Yet what is most noticeable for me as a doctor is the care and respect with which they speak to their father and treat him. There’s nothing artificial about their attitude, which makes it special! They take his permission for every change we agree to make, explain him and patiently wait for his consent and questions. They hold his hand and even ask him whether it is ok to walk ahead! Rarely do we see children from very affluent families being so careful and loving to their parents.

In an era where many a times sons and daughters accompanying their parents either bluntly ask “How long is the parent going to survive, What basic minimum can be done without much expenditure, Is it okay not to treat at all” etc., when we come across such extremely gratifying moments, I feel that all is not lost. By experience now I don’t think that this belongs specifically to Indian culture, in fact people from most cultures in the world treat their parents far better than many Indians. The very fact that Our govt and courts have to make laws and take steps for abandoned and neglected parents speaks a lot about what is happening. In fact, the more affluent a family is, the less likely that the children genuinely care for their parents.

Taking for granted that the parents do not want to live longer, deciding on their behalf that expensive treatments are useless and unwanted, oversimplifying all complaints as ‘age related’ and completely neglecting medical care are common observations in our practice.

This moment therefore brought me a beautiful ray of hope.

21st July 2018 is Mr. Harkishan Budhrani’s 85th Birthday. While I pray for his excellent health and perpetual happiness, I wish that every parent is as fortunate as him and that Mr Budhrani lives on many more hundred years as an example for all of us.

©️ Dr. Rajas Deshpande

Victim? Dr. Reena’s story

Victim? Dr. Reena’s story

© Dr. Rajas Deshpande

“I am being victimised, Sir! I have tried to do my best, but my senior has developed some prejudice against me and has started to find faults with everything I do. I don’t know, I feel suicidal sometimes” the resident doctor Reena said, breaking down. She was into medicine, one of the toughest branches for post graduation.

This was a difficult situation. It is very well known that some seniors and teachers do take advantage of the situation to mistreat and misuse their students or subordinates. It is also well known that both men and women in every profession, including medicine, have strong gender biases and favouritism. Sycophancy is so essential in India, that I wonder sometimes whether an official bachelors / masters “Chamchagiri” (sycophancy) certificate will be necessary before people are selected for their jobs.

I gave her some instructions to ignore words and minor incidences, and concentrate on doing her official duties with concentration. I also counselled her about how to handle egoistic, arrogant seniors. She was supposed to follow up next week.

That weekend, I met a colleague of mine, Dr. Anand, in the coffee shop. There was no OPD, it being a Sunday. We sipped coffee in the canteen, telling each other funny stuff about other colleagues. Medicine provides great entertainment too, in the form of various types of doctors, and we start with ourselves usually. © Dr. Rajas Deshpande

Just then, another doctor came in, Dr. Anand invited him to join us and introduced me to him as Dr. Ashwin. “Ashwin was my junior resident” said Dr. Anand, “and one of the most brilliant students. He’s a wiz. He wanted to work for the downtrodden, so he has continued to work at the govt. hospital after his MD. Most dedicated! That’s why most girls around us liked him and we all envied him”. It is rare for Anand to praise someone this much, I was quite impressed and happy.

But Dr. Ashwin appeared quite disturbed. Dr. Anand asked him if he was ok.

“No, yaar. I am facing a big problem. There’s this girl in my unit, who has made my life hell. She has filed complaints against me to the dean, my name is all mud”.

“Complain against you?” said Dr. Anand, truly surprised “Even your wife never complains against you”. He was trying to lighten up the mood. © Dr. Rajas Deshpande

“Yes. But you know how heavy our PG duties are. This girl, besides being lousy and careless, refuses to finish her work, constantly looks at the watch and doesn’t want to be corrected. How can we tolerate carelessness in medicine? There are patients in the ICU and this lady keeps busy with her cellphone! I gave her a warning that I will complain, but instead, she went ahead and complained that I was harassing her, implying serious charges. Fortunately my wife and the dean understand the situation, but you know some people in the campus would rather see me down. I don’t know what to do. I am thinking of resigning”.

“Can you share her name?” I asked, cautiously. The guess was correct. It indeed was Dr. Reena.

“I tried to talk to her, I requested her to call her parents. Apparently she has grown up as a pampered child, her parents refuse to even think that she can be wrong. They started complaining that their daughter didn’t get enough rest and good food, that she has always been a super genius kid and how many a times even her teachers could not understand her genius”.

Now the picture was clear, with the other side of the story revealed.

There indeed is, nowadays, a rampant tendency to play a victim, especially to cover up for one’s own failures, inadequacies and lethargy. Children who allege that their failures are either because of their parents being over disciplined or completely negligent, boys who hate their parents and refuse accepting that they fell short of hard work and dedication because of too many diversions, girls who sometimes lie about “sexual abuse”, and employees who underperform only to blame it upon a racist / pervert / prejudiced boss are classical examples when stress factors are analysed well. There was one girl who alleged abuse by her step father, just to tell me minutes later that it was probably her imagination, and that she didn’t know if it was a dream! It was her mother who then revealed that the girl had always used that ‘dream reality’ sequence whenever she wanted something and was refused. © Dr. Rajas Deshpande

There indeed is rampant true victimisation in all these areas, and one must always stand by the victim. But the overflow of sympathy that drowns sense and reasoning (thank you, media and some movies!) must always be avoided. Differentiating ‘true’ and ‘pseudo’ victims is never easy especially because there always will be the social biases. Most Indian men unfortunately truly look down upon women, most seniors think that juniors cannot be more intelligent, parents often mentally overpower logic when dealing with kids etc.. Still there indeed are many who hide behind the “victim” tag, just to take advantage of the sympathy and protection it offers, using it to hide their own negative side. A lot of people use suicide threats, false complaints and other pressure tactics to emotionally exploit and threaten others. When this happens in a workplace, it poisons the whole atmosphere. There is indeed no protection for the true victims here.

Next time when Dr. Reena came to visit, I told her how I chanced upon the doctor who was “troubling” her. As expected, she cried and defended her stance, but after some gentle coaxing, when I reiterated that the actual problem must be dealt with, she agreed to have a meeting with Dr. Ashwin. I called in a female counsellor too, and in a few meetings, we could sort out the issue.

Medical career is, difficult, it is important to do every single thing perfectly and with utmost care and concentration. No one else can ever replace the life-saving responsibility of a doctor on duty. A doctor who isn’t fully attentive to everything about every patient can be dangerous.

Dr. Reena agreed to go by the duties allotted and improve her performance, while Dr. Ashwin reassured her that he had nothing personal against her, that she could always compare her duties and performance with her other batchmates. He also told her that now onwards he will mind his words better. She withdrew the complaint.

Dedicated to those such who have had this horrible experience.

© 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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A Medico’s Last Certificate

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© Dr. Rajas Deshpande

A continuous beeping filled up the air in the ICU. Over twenty hearts kept making rhythmic sounds, the nurses kept on silencing the false alarms that rung every now and then, and informing us about the ones that needed attention.

We had kept the cake in the doctor’s room, we were waiting for the right moment. It was well past midnight, we had all wished Dr. Steve a happy birthday, but the ICU was full and busy, we waited for an opportunity to cut the cake.

A very old Parsi man, just recovering from a massive heart attack, was not maintaining his blood pressure. As his alarm sounded again, we rushed to attend him: Dr. Steve, myself and our nurse Ms. Divya. As we adjusted his intravenous drips, he asked us our names. He was funny, and always made us smile in spite of the deadly shadows that surrounded us. When we told our names, he smiled. “See, there’s a Hindu, a Christian and a Parsi happy in this small 10 by 10 room, but they cannot all stay peacefully outside in this big country!” .. Dr. Steve, always interested in one-upmanship, smiled and said, “If you want, we also have a Muslim and a Sikh doctor outside. Shall I call them in?”

With the typical instant Parsi wits, the old man replied “Arrey no no bawa, all our ********** (I did not completely understand that word) political leaders will die if people from all religions come together”.

It was difficult to say whether we were treating his heart attack or he was treating out tired minds. © Dr. Rajas Deshpande

The CMO called, there was a new patient coming up, a young lady in respiratory failure due to pneumonia. As the nurses prepared the new bed, Dr. Steve took down notes from the CMO. Ms. Divya was one of our most efficient and agile staff nurse. Very beautiful and brilliant, she took responsibility upon herself with a passion that would put to shame even some doctors. We all knew that there was something going on between her and Dr. Steve, but both of them kept mum. I knew for sure though, because Dr. Steve had once confided to me about this crush he had upon her. However, overwork always suffocates personal life in a hospital.

The stretcher rolled in, noisy with calls of panic. The patient was gasping. Urgently shifting her on the ICU bed, Dr. Steve intubated her. She coughed a lot, and both Dr. Steve and Ms. Divya were showered with blood stained secretions. Dr. Steve had his mask on, but Ms. Divya had not had the time to put hers on. He angrily shouted at her, while adjusting the patient’s tube, to wear her mask. I finished securing the IV line, and started pushing in the emergency medicines. © Dr. Rajas Deshpande

The patient was a young lady, who had suddenly developed fever, cough and cold. On the second day she had become restless, was admitted in some nearby hospital, but as she continued to worsen in spite of treatment, she was referred to us. It was a viral pneumonia, an extremely invasive and dangerous viral infection had started filling up her lungs with fluid and blood. Just as her oxygen levels improved, she developed an irregular heart rhythm: viral infections often cause severe damage to the heart, a condition called myocarditis. In two hours after admission, the lady died. Horrible moments followed, telling her broken husband and stunned kids that she was gone forever. Completing the formalities and paperwork, we returned to the grind: we were medicos: there’s no choice for us to sit down, panic, repent, mourn or run away.

No one was now in a mood to cut the cake. No one even spoke about it. Next night, Ms. Divya bought another cake, and we all silently wished Dr. Steve a belated Happy Birthday.

Jutst ten days later Ms. Divya developed fever, cough and cold. The same deadly virus, most likely. We all panicked. Dr. Steve took leave and attended her, as her family was far away in Kerala. She had come to Mumbai to earn enough for her family. In spite of all efforts, Ms. Divya passed away in just three days. The faces of her elderly parents and younger brother became one of the worst memory-scars in our lives. Shortly after, Dr. Steve developed the symptoms too, but survived.

I took him out sometimes, to bring him back from the pit of depression and shock that he had sunken in. One evening, when we sat silently on Marine Drive, he said, “I will never have a Happy Birthday again. You know, Divya’s family has no support at all. I have decided to help them out for some time, till we find an alternative”. © Dr. Rajas Deshpande

Staring at the ocean, I kept wondering: In this country, where crores of rupees are thrown almost every other day for even miniscule achievements in cricket and cinema, where millions are spent from public funds upon the useless travel, security, meetings and social dinners etc. luxuries of the super-rich MLAs and MPs, where billions are spent by every political party in elections, there are no funds for the nurses, doctors and other staff who risk or lose their lives serving their patients. If a bridge collapses and many die, if there’s a major accident due to lapses in administration, there is immediate compensation, in an attempt to seal complaining lips. But if a medico is injured or killed, the best thing our society has to say is: “This is because all doctors work for money, it must be the fault of communication on the doctors part!”

We walked that whole night, along the ocean, silently crying. Sometimes the only solace for a medico is the thought that someday someone will desperately need a good doctor or a good nurse, and not find them around. Many medicos who do extraordinary good to their patients do not get any certificates for what they do. Most don’t care. Because we carry our death certificates in our pockets every day. One last certificate that we work very hard for.

© Dr. Rajas Deshpande

Dedicated to the nurses and doctors, medical staff who suffered / died because they served patients, saving lives.

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“Why Don’t You Marry Her, Doc?”

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Dr. Rajas Deshpande

“Sir, she cannot walk, she is paralysed below chest since last few days. Her husband doesn’t care, he has abandoned her. She has no money or insurance for tests or treatment. I want to help her, I don’t know what to do” I told my junior consultant, who was having his coffee break with senior consultant and the departmental secretaries. He looked at me in a nasty way, and said “Why don’t you marry her?” and they all laughed aloud. However, although my professor smiled with them, he asked me to get the patient’s papers.

She was a case of Multiple Sclerosis, in her early thirties, and had lost ability to walk. Her sensation below the waist, control over urine was also lost. This ghastly illness of the brain and spine often cripples the young. In many cases, when such disability develops, divorces follow. The world as we doctors see it is far more cruel, deceptive and dangerous than most illnesses humanity knows. She was left with a small daughter and no income. © Dr. Rajas Deshpande

I felt insulted, but I was in a foreign country. The junior consultant was known for his sarcastic humour and enjoyed impressing women around him, often at the cost of others, like so many dwarfs who take advantage of their chair to achieve what they otherwise cannot. I chose to ignore him, and got the papers to our boss, who called a colleague to enrol the patient in one of the upcoming research trials. That would ensure her free tests and medicines for a few years. I told her the good news. She started sobbing, then handed me a note written by her:
“I am killing myself as I have nothing left except my daughter, I cannot look after her with my disability. I have no complaints against anyone. Please look after my daughter”.
In some time, after she stabilised, she said “Doc, I had come prepared to kill myself today. My daughter is sitting in the cafeteria. If you had not told me what you did just now, believe me, I was planning to drive my wheelchair off the roof today”. © Dr. Rajas Deshpande

We called her 10 year old daughter from the cafeteria. Little did the cute child know how lucky she was to see her mother again that day.

That evening, my boss, the senior consultant, took me out for a dinner. Once the red wine loosened strained faces, he started to speak: “Rajaas, I know you are kind and you want to help others. I know you feel for your patients. But I must caution you, don’t get carried away. Your job is clear: to listen, to advise the best line of investigations and treatment, to explain, and to compassionately guide. Don’t carry too much weight upon your shoulders”.
“Why, Sir?”I asked politely, “I feel inner peace when I walk an extra mile to help my patient. How can that cause me any harm? Didn’t this lady survive just because you helped her today?”
“Because it is a never ending burden. To be able to effectively help everyone coming to you, you must have too much money and too much time. Doctors seldom have either. I lost a lot of time and money, to realise that this cycle never ends, that newer and more people need your help every day, all your life. I almost went bankrupt, collapsed and quit under stress. Then I realised that I must limit this so I could serve them best the next day”. © Dr. Rajas Deshpande

It felt like dry reasoning at that moment. However, boss continued to help patients beyond duty whenever I asked him. Over years, I realised how correct Boss was!

My dear british colleague Dr. Mindy was trying to help a patient through her divorce, I accompanied her. As the patient opened up, she revealed to Mindy that although she enjoyed marijuana, her husband was involved in the sale of other illicit drugs, and that was one reason that she wanted to divorce him. Dr. Mindy involved a counsellor to help her out. However, after they decided to patch up their marriage, the patient told her husband that she had confided in Dr. Mindy. The husband came over and politely threatened her to keep all the information only to herself, otherwise be prepared for dare consequences.
We all spent many a restless nights after that.

Emotionally disturbed, helpless patients, those who are treated unfair by family often depend upon a kind doctor. They get quite restless at times, worry a lot and then expect an immediate hearing and resolution from their doctor. From suicide threats to blackmails, there are messages that pour in once that channel is opened. This sometimes wreaks havoc in the doctor‘s life, because being disturbed affects clinical practice and decision making. The small time left for self and family is thus shot dead. A patient who becomes emotionally dependent upon the doctor can turn into a nightmare for the doctor. Over years, I learnt to balance this, going out of the way only for the few truly deserving patients.

Thousands of patients have survived just because their doctor emotionally supported them in time, otherwise they would have died of lack of will to carry on. No one ever credits the doctors who become emotional back-ups for their patients: a service that costs them time and stress, without any income. That is unfortunately considered a “duty” of the doctor, to be kind and available at bad times, but to be forgotten in good times. © Dr. Rajas Deshpande. Many actually think that good words, compliments and “a satisfaction of serving” should be sufficient compensation for the doctor. Nothing fully compensates, although kind words do sometimes make one feel good.

However, what caused worse hurt to me was some of my own colleagues who made fun of me and many other doctors who went out of their way to help patients. “Impractical, unnecessary, worthless, drama”, and so many other adjectives are used by colleagues and even seniors/ some teachers for doctors, students, residents who walk an extra mile to help their patients. I was extremely fortunate that I met some good teachers who supported my efforts without mocking me, and I continue to meet students who carry on this noble trait forwards.

When I was leaving, the junior consultant came over for the farewell too, and told me in too many words how I must learn to be “Practical”. I gave him a reply that one teacher with advanced genius had taught me years ago, for people who do less themselves and advise others a lot. This reply saves a lot of time and energy, my teacher had told me, and its beauty is that people don’t even understand that you are saying ‘those two useful words’ when you reply like this:

I just smiled at him.

© Dr. Rajas Deshpande

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MEDICARDIA: A Doctor’s Diagnosis.

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© Dr. Rajas Deshpande

Rimless spects, ipad, T-Shirt and denims. Brilliant face, thinning hair. Attitude. A face carefully wiped off of any expression. The typical new age intellectual waited outside the ICU. Body language: severe anxiety.

“Doctor, do whatever you must, his convulsions must stop” said Mr. Prasad. His father was having continuous fits for over three hours, he was just admitted directly in the ICU after all the home remedies had failed. His oxygen levels had dropped to dangerous levels. Patient had ready aspirated during his convulsions. His food had regurgitated and entered his windpipe.

The last treatment for continued fits is completely paralysing the patient with general anesthesia, intubating and starting artificial respiration with a ventilator. There is risk, but lesser than if the patient continues to have fits. Every doctor, for every patient, must make a decision based upon the risk-benefit ratio. Every treatment, medicine or surgery, also has potential risks. The decision that can potentially cause someone’s death is not easy to make. Every doctor lives on the edge of this risk.
Add distrust and suspicion, and we are dealing with law more than with medicine. Welcome to the medico nightmares! © Dr. Rajas Deshpande

The critical care team had already explained the risk to the Mr. Prasad. He had signed the consent, including understanding of the critical condition. We intubated the patient and ventilator was started. The fits stopped. A chest physician was also involved in the treatment. Monitoring of the brain waves still showed abnormal currents in his brain, so he was kept paralysed next two days.

On the third day, the patient developed fever, most likely he had developed a chest infection, so common after aspiration. His condition worsened, his blood pressure dropped. We informed the family.

“Why didn’t you prevent this?” asked Mr. Prasad.
“Sir, have you ever had any cough, cold, fever?” I asked.
“Yes, many times. What has that to do with my father’s infection?“ he replied.
“Why couldn’t you prevent it?” I asked, “Anyone can develop an infection or a heart attack anywhere outside the hospital and it is ok, but if it happens inside a hospital, why does it suddenly become a doctor’s fault? Hospital acquired infections are possible in spite of all precautions, in the best of the hospitals across the globe. The elderly population is especially more prone for infections.”
This being a routine question, there was no reason for me to lose my patience. © Dr. Rajas Deshpande

Our team worked hard to maintain the unconscious patient alive. His heart rate fluctuated, blood pressure dipped to non-recordable sometimes, blood sugars went high, liver and kidney functions were deranged, but we kept on playing the “Medical Chess”, where one doesn’t know what move nature will make next, the only possible next step is to accurately, promptly and wisely counter that complication.

His lungs started failing, the chest physician advised steroids. At this stage steroids could either be life saving, or could cause havoc by worsening the infection. Mr. Prasad was explained the situation.

“What are the chances of survival and complete recovery?” he asked.
“Unpredictable, Sir” I replied.
“Then why use steroids?” he asked.
“If we don’t, the chances are less than if we do”. I replied.

Steroids were added. The patient stabilised and then started improving gradually. Over next five days there was a dramatic recovery. Steroids were stopped.. Mr. Prasad remained expressionless, questioning every move. Three days later, once he started breathing by himself, the ICU team informed me that the patient could be extubated- the tube for ventilation could be taken out. I was in the OPD, I okayed the decision.

In a few minutes, Mr. Prasad rushed into my OPD.
“Doc, my father cannot speak. He has lost voice”. He was quite angry and anxious.

“Let me check” I said and went to the ICU.
The patient was otherwise fine. The throat tube inserted for ventilation sometimes causes swelling in the throat, involving the vocal cords, and such “hoarseness” or loss of voice is common after this procedure. Using steroids facilitates recovery, but in this case, it was now risky to use steroids. We explained the situation to Mr. Prasad. © Dr. Rajas Deshpande

“When will he recover from this?” he asked.
“Usually two weeks, but still one cannot say exactly” I replied.

“Why didn’t you tell this to us earlier? This is atrocious. I will file a complaint. We will go to the court. My friend is a reporter. I will also write on social media about this, that because of the treatment here my father lost his voice” he started shouting.

He did file a complaint with the hospital. Everything was on paper, everything was medically and legally correct. Still the administration must ask me questions and I must reply. Many long emails and documentations followed. One reporter called and enquired about the case, I explained her the situation.

I didn’t sleep well those five nights. Medicolegally we were safe, but who was to deal with the media allegations, the resultant defamation, irresponsible hurtful comments by every TDH on the social media?.

The patient was still under my care. I saw him daily, he was making good recovery. His voice became normal in next three days. He was shifted to the wards and then discharged. He was advised to continue anticonvulsant medicines. Mr. Prasad did not say a goodbye, didn’t write a feedback, he didn’t withdraw his complaint. They just disappeared, and did not follow up. I kept on dealing with the paperwork for a few days even after discharge. I still had a thin bleeding layer of patience left. © Dr. Rajas Deshpande

About a month later, at late night, I got a call from the casualty. The same patient was convulsing. Mr. Prasad had requested to call me.

He revealed that after the discharge he had searched for ‘the best’ neurologists in India, took his father to two of them, and was advised to continue exactly what we had advised. Then he researched internet, found an “ancient remedy” for epilepsy rediscovered recently by a famous baba, that guaranteed complete cure. They had stopped the anticonvulsants advised by me three days ago, as the Baba’s site blasted all modern medicine and the dangerous effects of allopathic drugs.

My remaining patience was destroyed, However, the patient was my first responsibility. I advised the treatment, we intubated the patient and started ventilation again.

“What are the chances, Sir?” asked the rimless eyes with expressionless face.

“We have started with the emergency treatment, the patient will be shifted to the ICU. I cannot accept this case, please admit your father under another specialist” I said. © Dr. Rajas Deshpande

“Look doc, I am sorry if you felt bad about last time. We paid full bills and we will pay again, we have mediclaim. I want you to treat him” he said.

“I don’t work for the mediclaim companies. You cannot pay me for the damage you caused to my peace of mind, the waste of time you caused by writing falsified complaints. You cannot pay me for the sleepless nights because of your threats” I told him.

His face changed. Panic appeared on that expressionless face. He folded hands. There were tears in his eyes. “Doc, I am sorry. I got carried away by what people say about modern doctors. I will do whatever you want. Please save him. I promise I will immediately write an apology to the hospital ”.

Needless to say, a doctor’s heart has many hard scars, but it is the easiest to melt. It did, once again!

© Dr. Rajas Deshpande

Real experience, some facts changed to mask identity.
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