Friday, January 20, 2006

A Day in the Life of

It was the day before Eid and we had just finished rounds. There was a festive mood in the wards as the doctors were going home to celebrate with their families. We have four doctors in our ward and two are from out of town. They were the ones most excited as they rushed about doing their tasks so they could get the earliest bus out.

I walked into the doctors’ room to collect my bag. It had been a relatively long day with a non-productive working round so I was looking forward to going home, taking a nap and then getting some studying done. The week before I’d traveled all the way up to the inner city to get the latest copy of Parveen Kumar’s Textbook of Clinical Medicine and it was lying on my desk, all glossy with the scent of the fresh paper and promise. I couldn’t wait to start reading it.

As I slung my bag over my shoulder, Dr Salman, one of the senior residents, came in.

“Where do you think you’re going?” he said, grinning at me.

“Home?” I ventured.

“No, you’re not,” he said. “You and I have some discharge summaries to fill out.”

I groaned inwardly. Discharge summaries are the bane of any resident’s existence. Filling them out involves a long and tedious process of reading the patient’s file, going through pages and pages of hastily scribbled residents’ notes and then extracting the relevant details of the patient’s stay in the hospital. It was irritating work but Dr Salman had been teaching me regularly these past few weeks and it was the least I could do to return the favor.

“Sure,” I said.

We sat down at the nursing station with a stack of files. My first case was a lady we’d admitted for fever a month ago and her file was as thick as a brick. Just jotting down the salient features alone would take an hour. There went lunch. Beside me, Dr Salman was hacking through his file as well as simultaneously fending off attendants’ requests about what they could feed their patients.

“But she hasn’t eaten all night. How can she take her medicines?”

“Your patient is in uremic acidosis. It doesn’t matter if she doesn’t eat. We need to take care of her renal failure first.”

“But if she doesn’t eat, won’t she become weak, doctor?”

“We’re taking care of that through the IV glucose infusion. As soon as we correct her renal failure, we can start giving her something to eat.”

“Whatever you say, doctor,” the attendant said skeptically. “You know best.”

I smiled at the exchange. This being Lahore, food was a major concern here, even on the wards. Attendants associated eating with well-being and took any opportunity they had to feed their loved ones. It meant they would get better. But to have one attendant after another coming up to you, testing various dietary regimens against your clinical knowledge, could be very trying. A lot of the patients were critically ill and it didn’t take much to see that feeding them wouldn’t solve their problems. It took some patience to help explain all this repeatedly to the attendants and, to be quite honest, it wasn’t their fault. We worked in a government hospital and most of our patients came from lower middle-class socioeconomic backgrounds were the education levels weren’t very high. To them it was all confusion, no matter how many metaphors we worked urea and electrolyes into, and food and prayer was the only way they could deal with the situation.

“The problem is education,” Dr Salman echoed, speaking my mind. “The families aren’t very educated and so they can’t understand. It’s not like this in Western hospitals. There patients are very educated.”

Dr Salman had a curious habit of directing every conversation, whether it be the details of peritoneal dialysis or an evaluation of compression fractures, towards a treatise on the inadequacies of the government healthcare system. He himself had done his undergraduate medical training abroad, in Russia, and was used to working in a more organized setting. So any time any thing went wrong, and even sometimes when it didn’t, he would point out to me the failures of the system we were working in and how things were better abroad. When I first started working with him I found this habit a bit disconcerting, this constant comparison, but as time went by I got used to it and put it down to a chronic, albeit benign, malcontent nature. He was a good teacher and a very skillful member of the team and I enjoyed working with him.

“Are you done?” he asked me.

I looked at the mess of notes in front of me. “No, give me an hour and I’ll have them ready for you.”

“Alright, let me know when they’re done and then we can go and get some lunch.”

Lunch? Just over an hour later I was done.

We went back into the doctors’ room where Dr Salman pulled out a tiffin from his bags and proceeded to unpack his lunch. He was on call that night and his wife had probably made him a hefty Lahori meal.

He pulled out some sandwiches and cake.

“What?! Just this!” I exclaimed, only half in mock disbelief. “What kind of Lahori are you?”

“Who said I was from Lahore?” he said, smiling at me.

“Oh? Where are you from?” I said.

“Have you heard of Sheikhupura?” he asked.

“Yes, that’s close by.”

“Ok, have you heard of Nankaana Sahab?”

“Yes, where the Sikh visitors go.”

“Exactly, that’s where I am from. My father is a schoolteacher there.”

I looked at him in surprise. From his foreign education and his inscrutable movie star looks, I would never have guessed.

“So where do you live in Lahore?” I asked, quickly trying to conceal my reaction.

“We live in a rented house in Model Town. We are five, three brothers and two sisters. Three of us are doctors,” he said with some pride in his voice.

“Do they also work here?” I asked.

“No, not here. My eldest sister is a gynaecologist at another hospital. I’m the second one. Then a brother who is doing his internship. Then a sister, she is training to be a clinical psychologist. And last, a brother, who is a dialysis technician.”

“Our parents had a small plot of land. Seven acres. They sold that to send my sister and I to Russia. But when we came back and started our internship we were only paid four thousand rupees a month. I am the eldest and I had to support my family. You know how expensive it is to live in a city like Lahore. I took on two extra jobs, working at a private hospital in the evening after my regular job and then at another dispensary for two hours after that.”

I could only stare at him.

“It was a difficult time. For five years I worked liked this, sometimes up to twenty hours a day. I had to because I was supporting my family. I couldn’t start my training because I had no money. All the time I was running after money.”

“But things have become easier now. We managed to set up an arrangement with a private hospital here so that I have a good fixed income. Also, my younger brothers and sisters are educated now and can support themselves. Last year, my eldest sister got married.”

“Now I have some time so I can pursue my education. Last year, I started this training position in Nephrology. They don’t pay me anything here so I have to work at the other hospital but working here gives my experience some credibility so I can take the qualifying exams. Even today, before coming here, I went to do rounds at the other hospital early in the morning because I was on call here and wouldn’t be able to attend to those patients until tomorrow afternoon.”

“Here, try some of this. Let’s see if you can tell what it is made of,” he said, pointing to a small cake.

I broke off a piece and tasted it. The sharp, sweet taste of ghurrh erupted in my mouth.

“It’s ghurrh,” I said. “And what else?”

“Crushed rice. This is my favorite. My mother sends it from home. My stock is about to finish now so I will tell her to make some more.”

He smiled. “I’m sorry for keeping you. It’s Eid tomorrow. Go home.”

“Oh, no, it’s my pleasure,” I insisted. “If you need me to help you with anything else, just let me know.”

“Alright, after you finish, we can go and do the lumbar puncture on Bed 20,” he said, picking up on my enthusiasm for doing procedures.

We finished our lunch and went over to Bed 20. The patient was a young girl with Alport’s syndrome, a rare form of hereditary renal disease associated with nerve deafness. Saba had a family history of Alport’s syndrome, having lost two elder brothers to the disease. She herself was in uremic encephalopathy and we needed to do a lumbar puncture to rule out any other infectious process. Dr Salman was an expert in ward procedures.

We placed the child in the correct position, flexing her spine so that the intervertebral space would open up and allow us access into the spinal canal.

“We normally insert the needle lower down, where the spinal cord tapers off, so that we don’t accidentally puncture it,” he revised for me while simultaneously cleaning the area with antiseptic solution.

“Whenever you’re doing a procedure, the idea is to be very comfortable and relaxed. Tensing up only increases the chances of a mistake. When you panic you are more likely to inadvertently injure the patient. So relax whenever you do a procedure.”

He infiltrated the space with local anesthetic. The child winced.

“The needle we use is usually a 20-gauge. The 22-gauge is too narrow and flexible and the 16 and 18 sizes are too thick. 20 is the perfect size.”

He slid the needle smoothly into the interspinal space.

“There, I’m in. I can feel the resistance give way as soon as I’m in the canal. Now all we have to do is wait for the fluid to come out.” He placed a vial under the open end of the needle and waited patiently for the drops of cerebrospinal fluid to drain out.

“A lot of residents get very tense about this procedure. There’s nothing to get tense about. It’s a very simple procedure. And the more you practice, the easier it gets.”

“You do it very well,” I remarked. He made it look very easy.

“It’s because I’ve done so many. When I was working at the private hospital, I was the only person doing all the ward procedures. So I got a lot of exposure. You name the procedure and I’ve done it.”

I smiled. I could definitely believe that. I’d seen him put in a central line, a catheter that goes into the jugular vein, and, again, he’d made it look like child’s play.

“I was going through the records of the private hospital recently. They keep a record of all the procedures performed by the doctors there. In the six years that I’ve been working there, I’ve done 3500 central line placements.”


“So now, it’s very easy for me.” He closed off the vials and removed his gloves.

“Okay, now go home,” he said. “It’s almost eight in the evening. Eid mubarak. Thank you for helping me.”

“No, thank you, Dr Salman,” I said gratefully, “Eid Mubarak.”


Blogger yasmine said...

Wow, subhanAllah. May we all have that much patience and commitment and love in all that we do. Dr. Salman sounds like an amazing mentor, mashaAllah.

9:53 AM  
Anonymous Anonymous said...

You can also visit HealthCareerNet - Physician Jobs Search and search for Nephrology jobs.

1:42 PM  
Blogger Anjum said...

"wow, subhan'Allah" is right. great story, Aamir, i loved it. very "day in the life" but also a great lesson in patience and understanding of hard work.

8:08 PM  
Blogger karrvakarela said...

Thank you. I'm glad you enjoyed it. Dr Salman is an awesome person to work with.

4:54 AM  
Anonymous maddy said...

been reading ur blogs for some time now,mashallah very heart warming storiez.i have had very bad experiences with Pakistani hospitals and doctors .. i have yet to meet polite nurses and staff people! but after reading these blogs i will be expecting "jadoo ki jhaphiz" the next time i enter a hospital!

10:30 AM  
Blogger karrvakarela said...

Thanks, Maddy. Glad you enjoyed it.

I've had bad experiences at hospitals too. And you're right, the housestaff can on occasion be quite rude. As a patient or an attendant, I find that intolerable. But as a resident myself, I can see how that happens. Doctors and nurses in Pakistan are quite often overworked and underpaid and when you have to work long hours in a system that harasses you, a jadoo ki jhappi is the last thing you want to give someone.

3:30 AM  

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