But, as you voyage a few miles into the rural hinterland from any metropolitan city of our transforming incredible
A major problem that a non-maharashtrian doctor had to tackle while sitting in the out patient department was the substantial language barrier, which is so obviously inevitable when you are encountering patients from four different states in the Indian Republic where the dialect changes faster than the speed of the wind in these relatively barren lands; a true testimony to unity in diversity slogan summing our Nation’s obvious strength with its inherent weakness. Your conscience just does not allow you to get away by making some imaginary “can’t get you signs” in the air above your head to a patient whose language you fail to comprehend beyond a meaningless clutter of words, moans and groans that were never registered with the comprehension center of your supposedly best available grey mater in the country. This patient who has come to see you after purchasing a train ticket from the earnings of his last fortnight, still not sure whether the job he has just relinquished would be there for his taking when he gets back to work again; travels twelve hours in the general compartment of a passenger train crowded beyond its capacity with his wife and kids – as there was no one to take responsibility of the kids in their absence; has two big jute bags one housing the cooking apparatus and other the family beddings both at the moment were supporting the back of his wife, whose lungs were heaving suspiciously hard for her young age.
She was sitting on the floor with hands folded and tears trickling down her eyes, with her two children innocently looking up in absolute confusion towards you, probably trying to figure out something of a white coat demigod in his most animated forms they probably had ever seen, meanwhile vigilantly supporting their mother’s splinted right lower limb with their tender hands meant to play and explore; just because there mother is in pain and a patient who got well at this hospital has in very good faith sympathetically recommended the family to visit this department where supposedly the doctors are from some outer world and can treat probably anything and everything that comes in their way that too at a very meager cost. “Now you have a situation out here, doctor” I mumbled to myself; already feeling the heat of the vertical sun in the tropical summer noon of the year 2002 coupled with an emotionally and academically challenging situation that I unexpectedly found my self into. The lethargy resulting from the lack of a tight previous night’s sleep, which till now was bogging me down had also suddenly stepped back, as if to allow me to summon all my thinking cells into action.
Suddenly a man broke from the queue and stepped in front offering to help me in a seemingly helpless situation, saying that “I can understand some part of this patient’s language and would communicate that to you, sahib”. After some deliberations I reached a conclusion about the history and examination and related the same to my consultant. This twenty eight-year-old female about a couple of months back had fractured her right proximal region of the thigh bone just by twisting her right lower limb while working in the fields; this area of the longest weight bearing bone of the lower limb, femur; is known to give way only when subjected to tremendous forces which are usually encountered in the settings of high velocity road traffic accidents. After about 8 weeks now, the radiogram done at our hospital of her right femur showed a break in the cortical continuity of the sub-trochanteric region that was not showing even the slightest attempt towards healing as if some unknown chemical mediator in her blood circulation had issued stern ‘not to work’ instructions to the ever working bone forming cells as regards to their osteoblastic (bone forming) activity. Only a glance towards the radiographic film was enough for the trained eyes of my consultant to exclaim “Oh Boy! She seems to have a pathological fracture!!” I was in my first year residency programe and was very much impressed by the clinical expertise of this Orthopedique chirurgien. The patient was advised admission in the Orthopaedic ward to ascertain the pathology that had rendered one of the strongest regions of the femur so very weak at such young an age, such that it was more than obliging to split at the slightest hint of the twisting forces that usually would have playfully and innocuously traversed the bony trabeculae in this region and is now just not willing to unite as if some stealth diabolique process was probably unabatedly eating into the very integrity of the broken femur and her spirit as well.
She was urgently admitted, all the baseline blood tests were hurriedly run, an ECG and a chest radiogram were also requested keeping in mind the background whining of her lungs laboring hard for that breath of fresh air that seemed to consume a lot of her energy and was in effect was exhausting her of the meager energy resources that she now seemed to possess. Every effort was made to make her comfortable on , she was helped into loose clothes, a couple of pillows were placed behind her back that helped to prop her up in order to assist in her fight to suck in each vital puff of air, an oxygen cylinder with nasal catheters fixed to her nostrils delivering the seemingly divine gas with every breath she was taking, an intravenous drip hydrating her with some essential electrolytes, glucose, water and some bronchodilators mixed in it with an aim to relax the already pressurized airways and a urinary catheter placed to chart out her output. Blood counts expectantly revealed alarmingly low hemoglobin level, raised renal function parameters which correlated with her clinical status; a thready pulse, low blood pressure, tiny droplets of sweat shimmering on her forehead and the urine bag was empty despite the amount of fluids being administered intravenously since last one hour. A wet X-ray film that was made readily available on request, on the very first glance confirmed what we have been hesitantly expecting; there wasn’t a trace of healthy lung tissue visible in any corner or zone, every inch of the vital lung tissue had been ruthlessly invaded by the white fluffy patches indicating wicked infiltration by that very evil process which probably had also halted the bone pieces form reuniting themselves. The patient was deteriorating with every passing minute; those pleading eyes, drooping eyelids and half visible eyeballs gave an impression as if a black tired sun that had lost most of its fire was preparing to sleep somewhere deep into waiting arms of horizon and soon the curtains would forever be pulled down on the show, ironically challenging the so called demigods of the human race, but probably it was too late in the day to save a life that desperately hoped to live for her innocent couplets and a doting but poor husband.
The primary focus of cancer, the devilish force responsible must have strategically started somewhere inside the body, but does anyone know where? There were now only some possibilities hurriedly jotted down on a piece of white paper under the heading of differential diagnosis daring you to investigate them, but do we have sufficient time to undertake an elaborate combing operation? What is the priority, zeroing onto that primary process just as a part of the so called standard treatment protocols, just to make you feel elated Yes, yes, yes! Now we know the evil resident in her body that had rendered her and us so damn pathetically helpless or just to be humane enough to impart limitless care with utmost sympathy for the fighting spirit trapped in a tired body being egged on to fight a losing battle, a stage where they might be parting forever? How and What should be explained to the patient’s desperate husband, that a bone had broken in her thigh (which he obviously was aware of before us); and that is soon going to die, when he knows for God’s sake at least that fractures don’t kill and that We as bone specialists at a such a big hospital are in fact are as helpless as he is? How is he expected to understand what is killing his beloved wife who was apparently fine till a week back except for a deformed thigh, when we as the so labeled master clinicians and bone setters have no collective clue of the culprit except some black theoretical possibilities on white? Is ignorance really bliss? I really still don’t know, it is very subjective, very situational, I suppose.
Had he knew this was going to kill her; what other things he would have done to reverse the verdict? Where possibly had he erred in providing her with an adequate and appropriate care, which she humanely deserved? What would have been the scenario in case he had reached the hospital steps a week or two earlier? He will think this for all his life and keep cursing himself. He probably was wishing now, that had he earned more money than he was now, or if the same person who had advised him to bring his wife here would have told just ten days earlier?
Caught in a tug of war between my conscience and probably his, I was painfully brought back to harsh reality when suddenly the panic stricken shout of a nurse pierced the calm but chaotic female Orthopaedic ward, “doctor she is gasping, please come fast!” I dashed immediately to her bedside, screening the entire corner bed from the stare of dozens of curious and hopeful eyeballs, as probably nothing in this world attracts more attention than a human tragedy! With beads of sweat on her forehead, my fingers reflexly but frantically searched for her weak radial pulse but no pressure was recordable, there were few drops of urine in the bag and her tired lungs had probably given up at last as she lay still. Her stillness was punctuated only by shallow but painful gasps sucking in a little puff of air, flickers in finger muscles and valiant attempts to open her tired eyes to take one last fleeting glimpse of her beloved family; all these ominous signs were being interpreted simultaneously yet differently by various persons; by them as her willpower fighting to live against the conspiracy of that unknown yet powerful, drowning natural force and by us as a clinically impending end of human life.
In these circumstances my consultant advised DNR – “Do Not Resuscitate” protocol to be followed, as in such cases wherein a systemic pathology conquers and exhausts all the energy resources and the compensatory processes in the body as well, the attempts to resuscitate are obviously doomed and in fact the resuscitation only painfully prolongs the end for the spirit, the body and the relatives as well. Contrary to what it means, the decision appears unethically remorseless to the ignorant onlookers; and I had a feeling that this probably was being interpreted by the husband and onlookers as a negligent lack of effort on the part of doctors or are they also a part of the conspiracy? Is Ignorance really a bliss or is it not?
Nothing is Absolute in this World, be it Science or be it Religion, be it Information or be it Ignorance, be it Love or be it Hatred, be it Profession or be it Passion, be it Aspirations or be it Introspections; actually nothing I feel can ever come close to being absolute other than the delusion of unidirectional totality that the term ‘Absolute’ itself represents. Everything is extraordinarily Relative with respect to Time, Place, Person and Situation and yet no one can introduce you to the relativity of this Universe, except You yourself, and that too certainly not with your material aspirations but with honest spiritual introspections slowly but surely over time. As you voluntarily make an effort to try and get gradually but irreversibly addicted to this divine yet scientific art of introspection, you will require tremendous patience and time as well but till such time let ignorance prevail within You and let it be a bliss at your own peril.
