A Modern Indian Medical Student Rationalizes Trauma
I have a problem. I’m calling it a problem because I’m no longer sure it’s beneficial for me as I used to feel – I constantly feel the need to do something productive. What I consider productive is something that’s taken time for me to wrap my head around. But in general, it seems to consist of acknowledgement from an authority I can consider respectable. However, sometimes the “productivity” branches out into other forms and I’m unable to include these outliers in my generalization.
For quite some time I didn’t feel like reading a book, or writing. And there most of my list of feasible productive activities ended. So I decided to try out something new, going to the hospital emergency.
Lots of students go to the emergency ward to spend time, look at cases and learn some basic skills. I’d always wanted to, but hadn’t been going because I felt it would eat up time that I’d rather use in studying for my upcoming USMLE exam. This wasn’t a very logical excuse since there were plenty of occasions when I wasted my time just lazing around on the pretext of ‘taking a break’. So this time I talked to one of my friends and he agreed to go to the emergency block with me.
I’d only ever visited the emergency ward before with my friends when something went wrong for them: thorns in the feet, hypersensitivity reactions, finger fractures, a complete tibial and fibular fracture, cannabis overdose, sprains, and once, an attempted suicide. It almost felt strange to be here in the emergency ward for personal reasons unrelated to the welfare of my friends. However, despite this moral mismatch, nothing about the environment was different.
Exploring the Confessions of a Modern Indian
All the beds were occupied by patients, with doctors, residents, nurses, and the patients’ relatives hovering around them. There was an overload of patients and so extra beds were lined up at the entrance with worried family members reassuring their loved ones. There must have been crying, sadness, anxiety, and other negative emotions in the atmosphere, but I couldn’t sense any of it explicitly. It must have been there because I remember I had been shocked at the amount of suffering I witnessed during my first time in the emergency ward. But after having attended so many clinical postings, and getting accustomed to the hospital, everything just seemed normal. This is the best justification I can find for my lack of an emotional response, which could be categorized as tolerance.
The other option is that I’m selfish and don’t care enough about people. I don’t know which is true. I want to believe that it’s the first hypothesis, and statistical evidence would show that most medical personnel eventually get accustomed to the pain and fear their patients experience, but since I feel that this justifies something that seems morally wrong, I want to leave the option open where this could be due to my lack of competence. Maybe it’s a personal problem, and the rest of the world isn’t this way. In that case, hopefully it’s something I can fix myself.
Dealing with ragging
Back in my first year of medical college, when ragging was prevalent and popular and my batchmates voluntarily threw themselves into acts that stripped away their dignity, the reasoning was that if we bent to the seniors’ wishes, they would acknowledge us and help us later on in various aspects of medical life, such as mentoring us in the hospital. I hadn’t voluntarily given in to ragging by the seniors, and a part of me had been worried that maybe I wouldn’t be able to build connections with them. All that changed when I started playing football and realized that through the interaction I had with seniors that I met on the playing field, I had far more connections than all the supposed hot shots of my batch.
And so upon entering the emergency ward, I immediately spotted a senior who recognized me with a smile and asked why I was there. I told him I had come to learn something and he immediately asked me if I wanted to insert a ryle’s tube. I nodded enthusiastically and he led me towards a patient.
Confessions of a Modern Indian
The ryle’s tube, or nasogastric tube, is a flexible pipe that’s inserted through the nose down to the stomach. In fact, I had inserted one before, back at the time when one of my batchmates had tried to commit suicide. I’d been sitting on a bench in the emergency ward, a mixture of emotions playing out in my mind. That was when an intern had called out to me. In a daze, not knowing what I was doing, I walked over to him and he told me he was going to teach me how to insert a ryle’s tube. Maybe he hadn’t known what I was going through and just wanted to teach me something. Maybe he’d just wanted to lighten his workload by getting me to help, or maybe, as I like to imagine, he’d sensed how distraught I was and thought that this activity could help take my mind off things. Whatever the case was, his strategy had worked and I’d been temporarily relieved. However, perhaps because this incident happened over a year ago, or because my mind had been fuzzy during the whole crisis, I couldn’t recall the procedure now.
It didn’t matter, the procedure wasn’t too complicated, and the senior stood beside me the entire time, though there wasn’t much for him to oversee. My patient was conscious but wasn’t opening her eyes. She was old, obese, and clearly from a backward milieu, judging by her family members grouped around her. I told her that she’d need to swallow as I inserted the tube, but she gave my words no acknowledgment. My friend had warned me that since the patients were from remote villages and illiterate, they seldom understood instructions, or even if they did, they didn’t follow them. He’d told me that in such cases, we should just shove the tube in forcefully and keep going.
Bullying patients into obedience
Now recently I’ve been studying ethics as a part of my preparation for the USMLE exam, in which informed consent and such is a big deal. That’s not the case in India. For big procedures like surgeries, it works just fine, but for minor procedures and examinations, bullying works slightly better. Here we scold the patient and berate them for making ‘illogical’ decisions. I guess it is morally unethical, but at least it’s for the good of the patient. However, this justification doesn’t even make me feel better.
And so without waiting for my patient’s response, I inserted the tube into her nose. My senior told me that this was a difficult patient and yesterday it had taken 10 tries to get the tube placed correctly. I got anxious for a few seconds, wondering how I’d be able to get it right on my first try (technically second) when experienced interns had failed. I managed to get the tube through to her nasopharynx after poking around a few times, then I kept pushing. I wasn’t sure if my patient was choking, retching, or trying to swallow, but I decided to follow my friend’s advice and kept pushing the tube in. After some time I reached the mark on the tube that I was supposed to go to that I’d measured earlier, 60 centimeters. My senior handed me his stethoscope and I placed its diaphragm below the patient’s costal margin. My senior then attached a syringe to the open end of the tube and pushed forcefully, and I heard a gush of wind through my stethoscope, indicating that it was correctly placed in the stomach. After securing the tube to her nose with some strong adhesive tape, I thanked my senior and he left to get back to his busy workload.
India’s Health-Care System Is in Shambles
My friend had told me that on most days, half of the patients who came to the emergency ward were people who had been involved in road traffic accidents. The statement hit hard. Fractures, lacerations, internal bleeding, and the more deadly injuries like head trauma and even diffuse axonal injury, many of these were just the byproduct of rash driving, especially on two-wheelers. It made me think of a story I’d been thinking of writing a while ago, where in a futuristic society when all diseases had been cured, the only thing left were injuries from drunken violence, road traffic accidents, and assaults due simply to living in unsafe times. I had been thinking of entertaining the conclusion that what doctors in those futuristic times will be doing is just treating the symptoms of a sick society. There would be nothing ‘noble’ left to do, they would just be mechanics prolonging the meaningless lives of machines being played upon by the aristocratic forces above them.
What I hadn’t considered was that something about this story of mine might pertain to our current world. If road traffic accidents were half the cases in the emergency, this would almost inevitably be the same situation in the rest of India and maybe even the world. Half of the consumed resources, energy, and manpower were being spent on extremely preventable injuries, notably due to a lack of helmets,the prevalence of two-wheelers, and faulty transport. And even with all the abundant death and destruction it wrought, no one was taking it seriously enough to try and stop it.
Road traffic accidents in themselves were just a major symptom of a sick society, a sign we could observe before drawing a deeper conclusion. It reminded me of the movie ‘Zeitgeist’, which made the claim that the more a country spent on healthcare, the more sick its inhabitants were. Maybe the conclusion didn’t hold for low-income countries whose medical infrastructure was so below the mark that they didn’t have even basic commodities. But past a certain threshold, I could begin to see the logic in the statement. After all, half our resources were being used for driving-related injuries weren’t they?
I went into the pediatric section of the emergency department where children of varying sizes lay on beds, most of them with ventilators attached to their faces. One of the patients was a small girl. She looked around 7 or 8 years old, and she was gripping her ventilator tightly as she breathed through it. She looked calm, and I was impressed by her stoic demeanor. I glanced at her medical file. She had aspergillosis, a fungus that had infected her lungs on top of her genetic condition of cystic fibrosis. That made me glance at her age, which was listed as 13. I’d seen cystic fibrosis patients before, but it was always strange to see them. Their growth was so stunted that it was impossible not to misread their age on sight.
Another girl wasn’t doing so well on her ventilator. She was breathing and wheezing heavily, letting out moans of pain intermittently. Two doctors were in front of her, discussing her case. They were trying to get her to lie down so that they could get an arterial blood sample, but she was resisting them because lying down would exacerbate her difficulty in breathing. I glanced at her file, too – she had type 2 respiratory failure, which meant that despite her forceful efforts at breathing, she wasn’t getting enough oxygen or expelling adequate amounts of carbon dioxide. It was the first time I was seeing a patient like this, and I wondered how scary it must be, more than painful, to be trying to breathe, but being unable to do so.
Suddenly drowning didn’t seem like the scariest way of suffocating anymore. Perhaps a drowning person would have the hope that if they could just break through the surface, they would survive. But suffocating in the open, with adequate oxygen, while on a ventilator, not knowing why, and with no viable solution in sight – that was beginning to sound more painful. She had primary ciliary dyskinesia, which had led to bronchiectasis, and an exacerbation that produced her symptoms. I briefly wondered what her life would be like, even if she recovered from this acute attack. She had a genetic condition and would always be at risk of her symptoms worsening. She had an increased chance of catching infections, and she was most probably infertile. What was the life that patients like her would lead?
Looking for drama
My friend and I were called over by a resident who told us to take a quick history of the latest patient to arrive. The patient was a young female, probably in her twenties, in a wheelchair and seemingly unconscious. We asked her attendant what had happened. She told us the woman had a lot of chest pain. Allegedly, three days ago the woman’s husband had died and since then she’d been vomiting a lot and today began complaining of chest pain.
Chest pain immediately made me think of the possibility of a myocardial infarction, but I knew that couldn’t be the case because the patient was too young. We told the resident the brief history and she came over to ask the attendant further questions. She asked if the patient had been eating food to which the attendant replied that she hadn’t eaten since her husband’s death. The resident then scribbled a prescription for pantoprazole and ondansetron injections.
That surprised me. Ondansetron was a medication for vomiting and pantoprazole was for acidity. I asked the resident what the diagnosis was and she said that it was most probably gastritis.
Is Back Pain the Next Epidemic?
I was disappointed. Then I felt surprised that I was disappointed. Then I felt guilty that I had felt disappointed. I’d been expecting something more…dramatic. Maybe I was feeling this way because I liked the TV series House MD where each episode featured the lead doctor’s diagnostic prowess. Most episodes included a complicated medical diagnosis interwoven into the patient’s history and personality. I’d been thinking that with this patient’s history of losing her husband, maybe she’d attempted suicide, thus causing her symptoms. Perhaps she’d overdosed on NSAIDs which caused a gastric ulceration and hence the pain and vomiting. Or maybe she’d been so emotionally afflicted that she’d gotten a rare condition like the broken heart syndrome. But fasting due to emotional trauma, leading to gastritis was just so…bland an explanation. However, if that was the case, shouldn’t I have been relieved that the patient’s condition wasn’t serious? Wasn’t it wrong of me to have been hoping for an interesting but concomitantly more deadly diagnosis?
But this wasn’t a feeling that was exclusive to me. I’d heard plenty of times that residents in other departments got excited when one of their patients was diagnosed with a rare disease. And of course, there was the story I’d been told a few days earlier of how some of my batchmates had visited a rural public health center and they’d encountered a patient with testicular atrophy. Everyone wanted to inspect him and examine his testicles, and in the end, the patient ran away from the center angrily, claiming that he wouldn’t get any treatment there. Perhaps wanting interesting cases wasn’t abnormal for doctors or medical students, but something about it didn’t seem right.
We watched a resident try to insert a cannula in a few-month-old baby. But she couldn’t get the veins, which would be predictably difficult since the baby was so tiny and hence the veins too thin. The baby was crying with each jab and his mother was restraining him. The resident seemed frustrated and was clearly fatigued. Perhaps her hands were shaking slightly, or maybe I was just imagining it. She even asked the baby in frustration if he had any veins. Maybe she said it to relieve some of her tension, maybe it was meant to be humorous, but it was just kind of sad.
One of the nurses informed us that the patient in bed 10 needed a urinary catheter placed. We gathered the required equipment and walked over to the bed. I’d done this procedure before, on the occasion of my batchmate’s pill overdose, but like with the ryle’s tube, I couldn’t remember the procedure at all.
My friend told me that he’d need someone to assist him and I was glad to do so. When we reached bed 10, the patient’s attendant greeted us. He asked us which batch we were in. That unnerved me. The patient seemed educated. He probably wouldn’t want to know that we weren’t doctors, not even interns. But I didn’t think lying was a good option either. I told the attendant the truth, that we were fourth-year medical students, and he informed us that he was a resident in the department of dermatology and that the patient was his father. He asked us if we’d inserted a foley’s catheter before. My friend automatically replied yes, which was a good thing, since I doubt the resident would have allowed us to experiment on his father had it been our first time. Forget the first time, if it had been my father, I doubt I would have let anyone less than an intern perform the procedure. I had to respect the resident, and probably his faith in the teaching regime, or whichever virtue it was that permitted him to allow students to do the procedure. Inserting a urinary catheter was a little more difficult than a ryle’s tube since strict asepsis had to be maintained to prevent the chances of urinary tract infections, which were quite common.
The patient, like most patients, was only semiconscious and was making vague sounds occasionally. We pulled down his pants and I provided my friend with povidone-iodine laced cotton wads so that he could clean the perineal region. When my friend retracted the patient’s penile foreskin to clean it, the patient must have felt it and grabbed my friend’s hand to stop him. The dermatology resident pulled the patient’s hand back and let us continue. The patient resisted more vigorously, however, when my friend began inserting the tube in his urethra after squeezing lubricant in it. There were two simultaneous modes of feeling that I could indulge in. One was where I could try to imagine what the patient was feeling, with a tube being pushed into my urethra. I didn’t know what it felt like, having never experienced it, but even thinking about it felt painful and gave me an extremely strange feeling. But the other mode was where I could shut off this empathy and just watch blankly as the tube was pushed further through the patient’s urinary tract. This duality, with an off-and-on switch, fascinated me and I found myself switching between it during the procedure. However the patient’s aversion to the proceedure left me wondering about cases I’d read concerning people who presented to the emergency after having shoved electronic charging cables all the way into their bladder as a sexual perversion.
It turned out that inserting the foley’s catheter had led to some urethral injury and there was some blood leaking out of the patient’s urinary meatus. For a moment I was scared that the resident would shout at us, but he just calmly asked us to call a senior. As we went to find an intern, my friend told me that this type of injury was very common and that he was only calling a senior because the resident worked at this hospital and that had it been a normal patient, he would have just walked away.
The deeper ethical question
After another hour we decided to leave the emergency ward. While leaving I saw one of my batchmates come in, who had his clinical postings here at the time. He was a typical gym freak, a wannabe cool dude, belonging to a category that my friends liked to call toxic masculinity. He’d thrown away his self-respect to be accepted by the ‘cool’ gang of our batch, which he’d failed to do. He kept trying to come up with witty remarks on our WhatsApp batch group, and he’d kept pursuing a girl who’d made it abundantly clear she wasn’t interested in him. I didn’t need more evidence to label him as more towards the pathetic side.
COVID Failure: A Matter of Principle
People like him spawned doubts in my mind about how doctors could do good for the world and the public, and yet be such idiots in their personal life. This wasn’t just related to my ‘wannabe cool’ batchmate anymore, but to the rest of the medical fraternity, especially those who relished ragging and scolding students for no logical reason. It was a duality I’d been trying to wrap my head around since my first day of entering medical college. And if I accepted that such hypocrisy might exist, did the good they did for the public justify their incredible shortcomings as human beings? Perhaps I needed to accept that things could exist on a gray scale, but gray scale reasoning has always sounded to me like an excuse for not being able to come up with a good enough answer.
But what about incompetent doctors? Surely they were unequivocally bad, right? My friend snapped me out of my thoughts by asking me if after retracting the patient’s foreskin, we’d returned it to its position. I thought back and concluded that we hadn’t. That left me with an extremely weird feeling, which consisted of me imagining what it would feel like to have my foreskin permanently retracted. Hopefully, someone would notice what we’d messed up with the patient. If the foreskin was left retracted for too long, it could lead to paraphimosis which would need to be treated surgically. Thank god since we were just students we wouldn’t be held liable in case something did happen, but still…it did sound painful…
I assessed my feelings to see if I was satisfied with respect to what I’d come to achieve – my productivity. It certainly felt that I was satisfied – I was feeling good, I’d learned some stuff, seen some interesting cases, and had fun. Was I going to come back again sometime soon? I scanned my mind, but there wasn’t a very distinct positive response. I sighed. That was part of my problem, everything became mundane so fast. Consistency always became a chore, no matter how fun the activity was. I needed to experience rapid stimulation and acknowledgment to prevent passive tolerance from developing. It would probably take some time for the high of the emergency to wear off, until which I’d have to search for something else that I could delude my brain into classifying as productive.
The views expressed in this article are the author’s own and do not necessarily reflect Fair Observer’s editorial policy.