THE D... my first night @hospital

The ‘D’

October in Muzaffarpur was like a disease in approbation that made u dream of being under one of Alice in Wonderland skies and stuffed your nose with aroma of fresh air with a tinge of jasmine, but today it clogged his lungs and made him shudder from every nerve and sweat from every pore of his body. It was midnight and the fragrance outside didn’t seem to relieve him of the heat or humiliation within. Tonight desperation added a new element to his restless discontent. It rode his nerves like a hissing snake looking for somewhere to sink its fangs into.

‘Tapp’ fell another sweat drop on the glass of his specs. Hurriedly he took off the specs from over his big worried nose and gave another mighty push on the chest piece of the stethoscope placed on 12 year old Armaan’s chest. Shook his head in cringe. Another push… ‘Huh!!’...a sigh in guilt and he returned to his chair next to mine. Dr. R. Prasad or RP as we used to call him, from the Dept. of Emergency Medicine, was a man of larks and fun and I’d known him no more than for the guffaws he filled his class with, a speck of tickle with every knowledge word dispatched. But today this expression on his face was new to me. Fear? Guilt? Whatever, it was not good. Not knowing how to react I went on to RP’s place and positioned my hands on Armaan’s chest, gave few more mighty pushes. My ears yearned one ‘dhak’ from the stethoscope, in all the silence around. Nothing. “Push down on the center of the chest 1.5 to 2 inches and keep doing it. Pump at the rate of 100/minute, faster than once per second,” RP had taught us in the ‘Cardio-Pulmonary Resuscitation’ class, I reckoned. More pushes. Still nothing. The heart is dead.

Leave it Viraat, make a ‘D’ he said. “But sir we could use a De-Fib,” I revolted. ‘No use, make a ‘D’.’ I had never thought I’ll have to make a ‘D’ before making any prescriptions for the first patient of my life. All the years of hard labor, thousands of hours of studies, for a moment, seemed to crash to a NOTHING today, on the first day of my internship. Make a ‘D’, came his voice again. Make a ‘D’. But he was only 12. My mind rolled back to see what I was like at 12. I was a happy, pampered (not spoiled) child, studious, always dreaming of becoming a doctor like my dad. A teachers’ pet; nothing to worry about, a carefree soul, veiled from the most overt truths of life (or death), living in a world of my own. I didn’t deserve to die at 12 I thought, but nor did Armaan or anyone else. May be I was just lucky. RP probably understood the dejection on my face. “Get over your emotions Viraat; you have to face it everyday now.” I turned to go to my seat to make a ‘D’.

Armaan’s attendants around perhaps understood the expression on our faces. His father held me by the arm, “Ka hua sahib, bacha lijye, du-e-go bachwa hai, sab khatam ho jayega, dekhiye na, kuch kariye na, gareeb aadmi hai hum sahib, majoori karat hai, bacha lijye bitwa ko, chaar ghanta pehle thik-e tha, khelat rahe, achanak gir gaya sahib, kucho kariye na.” (What happened sir, save him, I have only 2 children, everything will perish, do something, we are poor, manual laborers, save my child, four hours back he was fine, playing, fell down suddenly sir, please do something). I could not make eye contact with him. Never in my life had I felt more helpless and culpable. The poignant guilt nauseated me. All I could do was keep silent. Struck by horror and agony the father eased the grip on my arm; with a grim face I returned to my chair. “Khatam ho gaya? Ya Allah!” he shouted. (Finished? Oh God!) The mother who till now had been a silent observer and only occasionally sobbing, gave a loud shriek as her husband started crying and beating his chest. She ran to Armaan, “Uth ja beta, aa ja, itna jaldi mat ja ammi ke chor ke” she broke down. (Get up son, come back, don’t go away from your mother so soon). Armaan’s elder brother who seemed to be the only literate amongst them made a quick move to where RP and I had stood for the CRP and made an effort at cardiac massage saying “aur thoda dekh lijye sir, shayad aa jaye.” (Please try some more sir, he might return). The mother collapsed on the floor, only waking up after few minutes; crying. Amidst all this a selfish me thought, ‘God why me, why do I have to see all this on the first day of my internship?’

‘D’, the same letter that ironically spelt Doctor too, here was for Death certificate, a one which I had never made before. RP dictated the follow up notes that I jotted down on Armaan’s bed head ticket.

12.35 am- Pt. condition serious
Gasping
BP- un-recordable
Pulse feeble

Rx- O2 inhalation
I.V. fluid RL- 1 bottle
Inj. Efcorlin - 1 amp. I.M.
CPR

12.45 am- Pt. gasping
CPR attempted
Rest to continue

12. 50 am No pulse palpable
No heart sounds heard
No respiratory movements
Pupils bilaterally fixed and dilated
Corneal reflex absent
Pt. is clinically dead

“Write death in capitals on the top of the BHT. Give the cause of death as Cardio Respiratory Failure on the ‘D’. Fill in rest of the details. Take the signature of guardian on dead body receipt and then give him the ‘D’.” he continued.

I went on to filling in the ‘D’ as troupes of memories from two hours back surfaced up. A worried father carrying-in his son in arms hastily entering the ER. “Sahib dekhiye na ka hua hai, achanak-e beehos ho gaya.” (Sir, please see what happened, he blanked out suddenly) “Purja banwaye ho?” asked a reluctant RP. “Counter se purja banwa ke aao.” (Have you got a receipt made? Get a receipt from the counter.) “Viraat see what it is, your first case” he said. My first posting as an intern was here in the casualty department and today was the first day, night duty. I was more than happy; I had spent a full ten minutes in getting ready. Washed my face, wet the hair and combed it sanely; formal trousers with pleats, belt buckle right in the centre, watch on the wrist, cleaned the spectacles twice, confirmed that the pleats from ironing the shirt were symmetrical on both sides, polished my shoes, hung the stethoscope round my neck, two pens- blue and black, looked at myself in the mirror, double checked everything. In simple words I looked like a decent doctor. ‘Here I come world, Dr. Viraat Harsh’ I had thought, as if I was THE messiah the world had been so long waiting for, the one with the magical healing touch, the blessēd one. And here I was, the messiah, oddly making a ‘D’. What a fool I had made of myself!

‘My first patient,’ I had thought proudly, and then gone out most professionally in taking a short case history. Nothing significant I could relate. Next, general examination. I was very cautious. Pulse, the first thing, I did not get it, looked for it a second time. Got it. ‘98/min, very feeble, regular’ I noted had down. Next, put my stetho to hear the heart and breath sounds. Nothing again. Then out of the blue came a ‘swoosh’ as I saw him gasp. I looked at RP and shrugged in confusion. He came to immediate help. As he examined the patient, I talked to Armaan’s parents. I heard from them about things which were most irrelevant clinically but made me got interested in him. His father could not stop telling me how intelligent he was, and how notorious too. He always used to get hurt when climbing trees to steal mangoes from someone’s groves. And how he used to lie and bunk classes and still top the tests. His mother told me that he was good and loving and hard-working and went on and on over the same things again and again. He loved to play ‘kancha’ (glass marbles). Had won scores of them in local matches and used to hide them in a box behind the clothes in the only broken wooden almirah in the house, so nobody would discover them. He could fish with a rod, in the flick of an eye-blink, so smart he was. He loved mathematics and could mentally multiply any two two-digit numbers in fractions of a second. That helped manage the expenditure of the household as he was the only one so smart. He had memorized tables up to twenty. He had also taught his parents to write their names. His elder brother didn’t like to study. He liked helping his father in the fields, unlike Armaan, who wanted to study and become a compounder, or may be getting a job in the post office. Armaan had once eloped because his father denied him an ice-cream in the annual fair but had got caught by his uncle at the railway station, and had got a good thrashing. Only occasionally, they said, he used to get tired and start panting and sweating while playing. Then he used to sit down for some time; got relieved, then returned to playing ‘kancha’ for rest of the day. This was the only relatable info I got from the history. ‘Dyspnea on exertion’ meant a heart disease, most probably a congenital one. I passed this on to RP. But while we could add two and two to be four Armaan had started to gasp and his pulse got even feebler. All this came to me as I was making the ‘D.’

I looked at my watch to note down the time of death. 12.52 am. ‘Rado’ engraved on it caught my eye but didn’t mean much to me anymore. The word ‘TIME’ on the ‘D’ made me think. RP, I guess could read my mind. “Time is the strongest of all,” he said, “the greatest healer, the most prevalent, the most dynamic. Everyone comes in this world for a definite time. It’s then on him to make the most of it. Life changes every moment. What we do is therefore important. Our deeds change our time, our future. Life is like a water bubble, vanishes in a second; like a mud toy it can crash any minute. It’s not in our hands how we die. What we can control is how we live. That is the reason you chose this profession. What is important for you now is that you serve the people in the best way of all, even in the most adverse of situations. There is no place for emotion in our profession Viraat. Just service. ‘Karma.’ Like what is vital for you now is making the ‘D’, mechanically, not thinking much. This patient is just a number for you, the registration number. You are perhaps feeling bad because he was your first patient. But tomorrow you will not even remember his name. I can bet you on that. And you know very well I am a stingy person.” Both of us smiled. I made the ‘D’ and handed it over to Armaan’s parents. I knew RP was right and that I would not even remember Armaan’s name a couple of days later. He was just a number for me, my first patient. My patient number 1. But I did not want to remember him just as a number. That day all I could think of was mentioning him in my small private diary, the experience at making the first ‘D.’

I just returned from the hospital before writing this article and opened my private diary. The page that opened said-
‘October 10th 2009 - joined internship. 1st patient-Armaan Hassan had come gasping. All I could to was CPR. Expired on the examination table, probably from Congenital Heart Disease. Made me sad. Making a ‘D’ was difficult.’
I made an attempt to recollect how many ‘D’s I had made since then. I had forgotten the count. Today itself I made three ‘D’s. I remembered none of these patients’ names. I just remembered the numbers; bed numbers 3, 6 and 8. And I was not sad about anything, or even concerned. As an intern it was my duty to make the ‘D’s for the patients who expired, and so I was doing it. But somehow I can not get Armaan’s face out of my mind. Not that it haunts me but whenever I think of the day I joined internship it comes to me. No, it doesn’t make me sad anymore. Nineteen days later, today I still remember his name. And I don’t know why. Will I forget it in the future? Time, ‘The all powerful and healing’ shall decide. But in a way I don’t want to. My patient number 1.