The word ‘Declaration’ is so easily associated by many of us with an announcement that a seemingly courageous but equally anxious captain of a cricket team confidently makes, though he clearly knows in his mind that his decision would be vindicated only in a sensitive hindsight with no one including himself knowing whether he would be presented with bouquets or brickbats in the coming future. To stop playing when you are on the top in the game, in a position to command the proceedings and force the opposition to bat in seemingly hostile circumstances based on the premise that your team is in a position to dictate the terms to the opposition and can easily force a win for your country by blowing the opposition away; who on the other side obviously is under tremendous pressure, more psychological than physical, to bat on a devilish and deteriorating wicket against a demolishing bowling squad, with a mountain of runs to chase down in order to save a match and a reputation at stake, more so when you are playing in front of your home crowds.
No one, not even the declaring captain, knows how much lead is enough to guarantee him a win or when is this enough, enough? There are just probabilities, possibilities and priorities based on his experiences, facts and ‘at-the-moment’ gut feeling. Are their enough runs on the board? Would he be able to defend this score with the bowling armamentarium at his disposal? Would the wicket behave in a way expected to, on the fourth or fifth day? Should he ask his team to bat a little longer to have a more comfortable cushion of runs? Should he ignore the personal milestones his team mates are about to achieve for the sake of team and how would they feel as a team or individuals in case neither the milestone is achieved and nor the team manages to win? Can the opposition batsmen really meditate on a 22 yard strip of grass and dust to squeeze out an improbable draw or a highly improbable upset win? Well, irrespective of the result, the declaration would die its own natural demise over the course of time. A few accolades or abuses here & there and that captain gets another chance again in his career to improve and be able to corner the opposition again from where there is no escape and then strangulate them to defeat in the dust and grass bowls. We have seen this happen quite many times in our lives, being beamed live into our living rooms and then being elaborately dissected out the very next day in print, at work and with almost everyone having their own eccentric views on how the things should have been handled out in the middle but the as always the mass memory is too short either way and the decisions end up as being a part of statistical books and videos.
In the summer of 1998; Vikram was working as a Resident Medical Officer at a rural health care center about 36 kms from the historic
Now, you just imagine a scenario where a declaration might make a difference so tremendous to the very existence of a human being, who is so very much emotionally a part of so many others, rather involuntarily woven around in the innately fragile threads of relationships. Your words pronounce him either ALIVE or DEAD; thereupon he is either taken to a better health care facility by his attendants with a ray of hope or he is shifted to the cemetery to be with the dead for rest of his death and their lives; you either re-strengthen the bonds of the innumerable sagging relationships that he is currently into or you might just cruelly strip all his relatives of their respective relationships for their lifetime. It all depends on you and you alone, your judgment, your clinical acumen, your gut feeling, your experience and a mind-boggling permutation of possibilities and probabilities all centripetally whirlpooling inside your grey mater and all the more treacherous becomes this seemingly easy task at hand when you have to perform it for the very first time in your medical career, independent, unaided and unsupervised; in the pitch of darkness, in a remote village hospital, closely scrutinized by scores of expectant eyeball pairs from every nook and corner around you and where the only guiding light source is the pale light emanating from an old blinking torch or the light within you, which is visible to none including yourself. The experience is undoubtedly a life transforming one but unlike a cricket team’s captain who has few coaches and eleven players around him, a few of them senior and more experienced ones to facilitate his decision; you as a doctor are immensely lonely and you need to hold onto yourself lest you loose yourself too.
On a calm, cool but moonless Saturday night at about 0300 hrs, Vikram was as usual on rotating weekend emergency duty, with all his colleagues enjoying the weekend in city catching upon the latest horror cum action flick ‘Omen’ in order to chill & thrill their frayed out nerves after a hectic week that just went by. Suddenly, the shrill telephone ring pierced the unruffled silence of a dull, dark, eerie night with echoes reverberating in the long empty hall way, Vikram had just lazily dozed off with his head still half placed on the 14th edition of the Volume I of the Harrison’s Principle of Internal Medicine, the pages of the medicine Bible were about half curled and hysterically fluttering beneath his heavy head as if they were trying to draw his attention to the emergency call in casualty or may be they were collectively trying too hard to find a way out of his heavy snoring head under a speedily rotating ceiling fan and a visibly awake, alert but dumb tube light watching down from the adjacent wall. The echoes of phone had any but little effect on doctor’s sleepy ear drums but the fluttering of pages had now been joined by heavy foot falls in the corridor as if someone was rushing in to wake up the duty doctor, heavy thumping of fist on the door followed, this had at last somehow managed to register only a soft polite knock onto his still slumbering cochlea. ‘Comii………iing maa………...aaannn’, a deep throated and visibly irritated, groan escaped from his dry lips, adjusting his specs over his nasal bridge he rushed towards the door without slipping into his slippers, that had been so loyally waiting since the moment he had slipped out of them and jumped into the bed; the book and its pages heaved a sigh of collective relief and the fluttering pages turned over to catch some breath and take a nap, in the process opening up the next section which Vikram had probably planned to read that dark lonely night.
“What is it? Is someone Dead? You scared the hell out of me” blurted the doctor, least bothered that sometimes one’s reflex subconscious utterances and thoughts would, with lightening speed, get transformed into real life situations."I don’t know Sir, Nurse said you were not reachable on phone and their was an emergency situation in the casualty premises, the relatives are many and shouting for the services of a doctor, please hurry up” replied the emergency attendant half asleep but seemingly terrified. Vikram rushed with him towards emergency wing, just managing to hurriedly slip into his waiting slippers. ‘Expect the Unexpected’, was the caption line on Rahul Roy’s posters pasted randomly on city walls, when the Bollywood flick ‘Aashiqui’ was a surprise blockbuster despite the director’s courage to experiment with some fresh faces, when Vikram was in high school. But, after years of remembering this tag line throughout his under grad career and its applicability in real life situations more so in the surreal medical profession, he had added a few more words to it. ‘Expect the Unexpected when you are least expecting It, are clearly & apparently ill prepared for It and then you also have no escape from It’, making it sound scary but that’s how life’s laboratory designs its practical testing systems even for the best of its prepared pupils and none knows it better than a medical mind. Vikram ran towards the casualty and reflexly but hurriedly whispered some panic laden questions towards the waiting nurse, “what happened, is it heart attack, a badly bleeding head injury or a crush injury, or is someone about to die?”; the tense nurse held the doctor’s elbow and took him aside to brief him, not responding immediately to his verbal volley of queries “Oh God! doctor relax, there is an unconscious patient in the jeep out there, the attendants wish the doctor to ascertain whether the patient can be managed at this rural hospital or do they need to drive him up to the city hospital about 56 kms away, they would only shift him down if you promised to make him conscious otherwise they don’t want to waste time out here; coz some neighborhood octogenarian Ayurvedic priest had pronounced him not alive, they are in no mood to believe him and are eagerly but irritatingly waiting for you, so please hurry up”. “Doctor I even over heard them whisper in hushed tones, once our patient awakes from deep sleep, they going to see that priest again for the obvious reasons and send him to hell; so you please be an angel, you are supposed to be and please put an end to their misery.”
No sooner than the inexperienced nurse had sealed her delicately painted, petals of lips, after whispering the facts and fears and had just somehow nervously managed to curve the lips a bit, for the visibly uncomfortable doctor; there was an unanticipated power failure. Such a dramatic, intellectually as well as emotionally and probably even physical challenging scheme of things, only got a little more gruesome with darkness pitching in and trying her level best to circumferentially envelop the daring doctor in body, mind, soul and spirit as well; whence his already clouded yet swiftly transmitting neural signals were trying hard to process, plan and present out a reasonably nice working solution to an intimidating situation. Whether the darkness was impeding or hinting or expediting Vikrant’s judgment would be a thing to debate in the hindsight? Because, such regular happenings even are too carefully planned in the heavens to be passed off as mere innocuous coincidences due to human errors or faulty cables.
Listening to the brief but hurried description, Vikram mumbled under his breath “shit I don’t know why but yes, I was dreading this and this only” he literally froze in his steps, with sweat breaking out on his forehead as he voluntarily tried to tighten up all his sphincters and motivated his self to back himself up to the hilt; as this wicked summer night was going to need it all that he had ever read or learnt or seen or discussed or taught or memorized or written ever, anywhere, during his medical school training program while being surrounded by his equally juvenile but enthusiastic colleagues but ably supervised by his helping and experienced seniors and being assisted out of the frustratingly out of control situations like these and many others; but never in his dreams did he ever imagine about confronting such spasmodic situations leave alone facing them in reality and in such an isolation so very atypical of our medical school training protocols. He had none but only himself to curse about being so short sighted and his inability to anticipate this fateful time and that doctor do not usually work in team of 11 or coupled 1s but single 1s, and that the two ones of the eleven would never be together for him and would usually be far isolated as they are now.
The black Mahindra jeep stationed with its back towards the casualty gate was waiting anxiously with open doors as if to hug him expectantly; a torch in one hand and a blood pressure apparatus with stethoscope in another hand, Vikram just about managed to walk confidently straight into the dimly illuminated rear of the vehicle trying his very best to prevent his mannerisms from betraying him and those eagerly awaiting the arrival of ‘the messiah of life’; without paying much attention to the dozens of piercing gazes and well trained ears to catch any word emanating from his parched, dry lips, lest their confidence gets better of his. In the dark eerie silence with a feeling of lump in his throat, he could overhear his heart pounding like numbing bhangra beats within his ears, beating faster then it had ever had to, in order to nourish the vital stress response organs, brain, lungs and adrenal and renal system; as he tried to search for the radial pulse of the patient.
The petit, obese patient was diligently positioned on the side seat, well wrapped in clothes with his neck on pillow and turned to right side but feet and arms exposed, the hand felt soft and slightly warm but pulse was not there to be felt, the more he tried the more his own capillary pulsations tried to fool and confuse him; then he slowly wrapped the blood pressure cuff on patient’s arm with the apparent confidence of a seasoned doctor, whilst his actions were slow his thoughts were rapidly analyzing every present animate or inanimate clue around the scene; as he only and only he knew how very terrified and highly uncomfortable was he sitting there and if and only if given a slimmest of chance he would have loved to run away from the casualty, fast as never towards the surrounding sugarcane fields, reach a secluded spot, with eyes closed towards dark skies he would have shouted at the top of his lungs, before spontaneously collapsing and breaking into a flood of tears and sweat, lie there exhausted and then effortlessly ease into sleep very sure of not to be disturbed for the rest of his sleep; but that was not the case to be on this dreadfully planned, testing and pitch dark night. The pressure of blood in vessels was not audible to his amateur ears.
His meticulous search for a heart sound by hand and stethoscope met with no success even and now with every sign adding up to the gradually swelling list pointing towards a potential dreadful declaration, made his heart even beat faster than in the previous minute. The pale torch light failed to elicit any reaction form the pupils, the black round windows to the brain, despite the repeated bilateral attempts to achieve the highly desired reaction. All the structured clinical examination protocols which he had so religiously memorized and mugged up during his medicine posting days had suddenly gone hay wire when he had tried to recall them, but the saving grace was that at least he was able to recall them one by one and who the hell out there was bothered about the order not at least the patient’s big burly attendants who were more interested in the declaration that he was going to deliver then the covert order of clinical scrutiny he was subjecting the patient to. There was no flow of air around his nostrils or one that would make his chest move up and down, deep painful stimulus on the tender zones also felt flat and there was no response what-so-ever that would have hinted towards potentially salvageable breath of life pooled anywhere in the body. An old creaking ECG machine somehow managed to produce an unconvincing flat trace adding more to his anxiety then allaying it. Taking his time to assess, reassess and re-reevaluate, knowing that only his clinical skills, acumen, knowledge and gut feeling would be the four pillars to lean stably on; Vikrant started to talk with one of his attendants stabilizing the patient’s head, breaking the uneasiness that had crawled up into the entire situation around him and started with some personal questions such as to patient’s name and age. “Bahadur (meaning brave, it struck him like a flash that he needed to be brave like the patient, testing him so ruthlessly even when he was even not there probably), 45 years” came a soft reply with an obvious emotional question posed in the answer.
“What were the problems with him? What had happened to him? When was he absolutely fine, talking to you?” asked Vikrant very respectfully, softly and sympathetically while continuing with his diligent search for any subtle signs of salvageable life. “We were all having a party with non-veg meals mixed in between with cocktail and some hilarious moments were being shared by the most humorous of us, Bahadur, and suddenly he collapsed in the midst of a hearty laughter, we all were very drunk and thought he was probably spicing up the laughter with his acting skills, it was after about an hour or so did we realize that something might be seriously wrong with him and then we summoned the old neighbour hood priest from his sleep, who probably feeling sleepy did not examine enough and decided that our friend was not alive, we were not happy with his approach and delivery of the decision, so we have brought the patient to you.” Did he vomit or cough or call for help or did he talk after the collapse ever? Politely enquired Vikram and both the questions were responded to in negative. Was there ever any movement of his limbs or toes and fingers? No doctor was the reply. Did he wet his pants after the collapse? Yes he did, but we changed the pants before coming to the hospital. Getting certain with every passing second about the fact that the patient has probably expired his last, now he sympathetically needed to address the obviously unsaid but discomforting query, hanging thick about the patient’s existence.
A fear just kept on poking him, “what if he is not dead and he is still alive and in a state of suspended animation, which I am not able to comprehend because of inexperience and the fear plus anxiety of first independent declaration” but he had to take a decision with respect to the declaration in front of the attendants and hospital staff and none could ever imagine the turmoil he was in and their was none for miles together to discuss. Is there any way to be absolute that he is not alive for sure? none other than sending a dead man 56 kms away by giving his relatives a bundle of false hope and reassurances, just to shift the burden off his shoulders onto someone else’s, contemplated Vikram. Was he so stupid a doctor, that he could not even differentiate between dead and live that any lay man would, leave alone treating fatal diseases or saving lives? The battle had begun inside his conscience for the calmness that he displayed was just a thick fake veil. His gut feeling was favoring his clinical judgment but the perennially dreadful question what if was poking him around???, had started juggling with his thought process and playing havoc, tormenting his soul and cells. What if I declared him dead but he can somehow be saved? What if he coughs or moans on their way back? What if he agonizingly shouts ‘Heeeeee……..lpppppppp……..Meeeeee’ form his funeral pyre? ‘In case that happens, I am gonna be on his place on the log of woods with fire beneath and engulfing’ shivered Vikram.
He regained his inner composure and softly yet slowly started explaining to the relatives what he thought about their patient’s condition and why was he thinking only on those very lines, not yet pronouncing the end but gradually building towards it using lucid logic and yet in a very systematic manner sensitively responding to their every query, suggestion and statements how-so-ever naïve it might be appearing to his expert mind; as if he was on their side of situation and not trying to wield his professional authority on the deadly declaration but showing his willingness to do anything to satisfy them any end. And a mutual discussion after about five long minutes was followed by sudden shrieks of despair, doom and worthlessness from the women and men who accompanied Bahadur with a ray of hope in their eyes. The tranquility of the darkest ever night was instantaneously and incessantly stabbed again and again this time by the elements of grief, disbelief, dejection and an indisputable ingredient of overwhelming shock more than anything else.
Vikram was reduced to a mere lonely bystander with his head looking towards the dark hovering skies praying, lest by any chance if his declaration betrayed him and Bahadur just managed to utter or even whisper a shriek of pain while being consigned to flames he would be reduced to a bundle of flesh and bones from a frame with a name and identity, being labeled as a deadly demon rather than being hailed as an holy angel.
Vikram spent rest of his night with shivers electrocuting down and flooding his spine and sphincters, half awake in REM sleep suddenly jumping out of bed each single time he could faintly hear or thought he heard an ambulance or police siren approaching the hospital gates, might sound funny but this can be very distressing and frightening indeed for an immensely lonely experience. A night after declaration can never ever be so troublesome and animated in thoughts, emotions and sleep for a cricket team’s captain as likes of these for a doctor. A declaration like this can also be perfected over years but rarely would be practiced or delivered again in such extremely isolated circumstances.
Next morning, as the first golden rays of the enlightening Sun caressed hospital’s soil with birds chirping around Vikram’s window he was again banged furiously on the door this time by many persons simultaneously howling ‘get up you sleeping doctor - …………..!!! But, this time thankfully, it was a collective banging by his teasing colleagues urging him to get up as he as getting late for the hospital. He raised his head to read the time in his wall clock that displayed the time in space as 0945 hrs and then glanced towards the section in the current chapter, in his favorite, still open Harrison’s textbook that he was scheduled to read before the horrendous night that had just ticked by forever, it read – ‘Incurability and Death’. His galloping heart skipped a couple of beats and then a transient loss of cardiac rhythm followed, the door banging flashbacked the nightmarish memories of the previous night; he inhaled deeply in frustration and disappointment and then again sunk into a deep snoring slumber that he badly deserved to recharge his self for the next innings on an isolated emergency duty. The last line of the pending section of medicine Bible read as: “One thing is certain; it is not for you to don the black cap and, assuming the judicial function, take hope away from any patient…hope that comes to us all.”
Sir William Osler.
