Professor Clouseau and the Science of Shadows

I’ve been ill for the past few days so I wasn’t going to work. A low fever, malaise, a general ill feeling. Exactly the kind of mood that doesn’t inspire any thoughts of work. My friend Subroto in Australia diagnosed it as an allergy to work. He had it himself. Apparently it’s a global epidemic.

However, three days is more than enough to cure one of any imaginary allergies. I went in this morning to find the senior resident beaming at my arrival.

“Dr KK! Where have you been? We haven’t seen you for so long!” he exclaimed boisterously as he hugged me.

“I haven’t been feeling well, Dr Anwar,” I mumbled incredulously. He wasn't usually this demonstrative.

“Oh? So sorry to hear that,” he commiserated. “How are you feeling now?”

“Much better, thank you.”

“Good.”

I put my bag in the doctors’ room and joined Dr Salman for pre-rounds.

“How’ve you been?” he asked me. “I wanted to call you last night to see how you were.”

“Then why didn’t you?” I shot back genially.

“Oh, I was busy in the ICU. We had a patient who started bleeding into his lungs and we had to put in chest tubes, first on one side, then the other. Then he developed renal failure and we had to do dialysis. It was a long fight. I came home at three this morning.”

“Did the patient make it?”

“No, he expired early this morning. I wanted to call you to join me. You would have found it very interesting. ICU practice is very exciting.”

“Thanks, maybe next time.”

“Oh, if it isn’t my buddy, Dr KK!” I heard a voice behind me. “How are you feeling now?”

“Much better, thank you, Dr Faraz. How are you?”

Dr Faraz was one of the junior residents on the team. He was new to nephrology, coming in a few days after I did, but Dr Faraz was a keen worker and more than made up for his lack of knowledge with long hours and thoughtful questioning on rounds. He was also one of the more amiable people on the team, subject to random outbursts of poetry and gluttonous discussions on food.

“I’m fine, thank you,” I replied. “How are you?”

“Good, thanks.”

“What have you eaten lately, Dr Faraz?” I teased him.

“We had aloo gosht yesterday,” he said mournfully. “But today the cook’s made chicken. You must join me.”

“Aloo gosht? That’s good food. You don’t like aloo gosht?”

“I do but only at home,” he explained. “You must understand. There is a difference between home food and hostel food. At home palak gosht tastes like palak gosht. Here I think the cook uses grass instead of spinach. The taste is very different. Same with aloo gosht.”

I started laughing.

“No seriously,” he assured me. “It’s not like home. But then, what would you know? You eat at home all the time.”

“Very true. I have eaten in a hostel for five years though. I understand where you’re coming from.”

“Good! Ok, it’s time to work,” he said, gearing up. “It’s Professor Clouseau doing rounds today.”

We all went back to our patients. Professor Clouseau was one of the senior consultants in the department. His real name wasn’t Clouseau, of course, but he reminded me so much of the character from the Pink Panther cartoons that I decided to call him that. Like his namesake, Professor Clouseau was also a quiet, unobtrusive person, completely unimpressive until he started teaching you. And then fireworks would go off inside your head. It wasn’t just that he knew a lot, which he did, but that he asked all the right questions, and in such a way as to guide your thinking as a physician and inspire you to acquire knowledge. After rounds with him, all you wanted to do was to go home and study.

Dr Salman and I were reviewing the progress of a patient that had been admitted with fever a few days ago. She had come in unconscious and comatose and slowly, over the course of a week or so, had managed to recover slightly on an aggressive antibiotic regimen. The progress however had been shortlived as she had slipped back into unconsciousness over the last two days. We were trying to locate the source of the infection.

“It could be a central nervous system infection. Or maybe an infection from the Foley’s catheter or the central line in her subclavian vein,” said Dr Salman listing the possibilities.

“How long can you keep a central line in?” I asked.

“Ideally, you should take it out after 72 hours,” he said. “But here in Pakistan most of our patients can’t afford this. So we keep it in indefinitely. It’s a risk factor for sepsis but we have to take that risk if we want to keep dialyzing the patients. They’re reluctant enough as it is to go on dialysis and if we don’t even do this, then we’re just inviting misery for them.”

I knew what he was saying. Over the past month or so, I had seen countless patients refuse dialysis. It seemed preposterous at first. They were in a nephrology ward, suffering from renal failure, a lot of it end-stage renal disease where their kidneys had stopped working, and yet the moment you brought up dialysis, it was like you were asking for permission to chop off their nose.

“No, doctor sahib, not dialysis!” they recoiled at the very mention of the word.

“Why not? It’s a perfectly safe procedure. And you need it. Without it, you will only be making things worse for yourself.”

“No, I will get better on medicine. Just give me the medicine and I will get better. I don’t want dialysis!”

“But why not?!” It was exasperating.

“I don’t believe it works.”

“What???”

“I think it will make me more ill than I already am. Please, doctor sahib, just give me the medicine and pray for me and you will see. I will get better.”

“Ma’am, if you were going to get better with just medicine, we would have been delighted to offer you just that. But the situation cannot be controlled simply by medication any more. You need to get rid of all the waste product accumulating in your body and dialysis will do that for you. Otherwise they will just go on building up.”

“I don’t want dialysis. Please.”

It was like talking to a brick wall. Quite often we would have to have two or three different people coming in to talk to the family and explain the need for dialysis. To be fair to them, I understood their concerns. Dialysis was very expensive. Each session costs about two thousand rupees and most of these patients need two sessions a week for an indefinite period of time. It can be tremendous burden on the family, especially in our patient population that came mostly from the lower socioeconomic classes. Still, if it was between saving your life or saving your money, the choice should have been to save your life. Anybody could see that.

“How is she doing?” Professor Clouseau had joined us.

“Not very good. She’s slipped back into the coma again. We need to do a lumbar puncture to see if there is a CNS infection,” Dr Salman replied.

“How long have the lines been in?” Professor Clouseau asked.

“It’s been a while,” Dr Salman told him.

“Ok, take the central line out and send the tip for culture. Also the Foley’s catheter.” He turned to me. “Bacteria colonise these surfaces and seed the bloodstream with infectious particles. You’ll notice that whenever the nurse injects something through the line, the patient experiences a spike of fever. That’s the bacteria being released into the system.”

“How soon should you take the Foley’s catheter out?” I asked.

“The risk of colonization is 10% per day. So in ten days, there is a 100% chance that the catheter has been colonized. How long as it been in, Salman?”

“About two weeks.”

“Take it out. What about antibiotics?”

Dr Salman explained that she was getting powerful, broad-spectrum antibiotics.

“But there’s a cost issue, sir,” he said. “The relatives say it is very expensive for them.”

Professor Clouseau turned to the attendant.

“We realize the treatment is expensive but we don’t have a choice. If we don’t treat like this now, we may lose the patient.”

“It’s difficult, doctor sahib,” the lady said in a quiet voice.

“I understand, ma’am, and we’re careful not to prescribe any overly expensive drugs. But you must realize that this is no ordinary infection. It’s not like a sore throat where you can scrimp on antibiotics. If we make any more concessions to the treatment, we’ll be doing nothing for the patient.”

The lady didn’t reply.

“It’s difficult practicing like this,” Professor Clouseau said, turning to me. “We have to use sub-standard drugs with poor bioavailability. The patient has several sources of infection. Cultures may reveal the need for powerful antibiotics but we can’t give them because the family can’t afford it. So we have to make do with second-line agents. It’s like shooting in the dark.”

He picked up the X-ray and examined it.

“Nothing in the chest right now.”

“Is that a lesion in the right upper lobe?” Dr Faraz asked, pointing to a hazy rounded opacity in the right lung.

“Looks like an old tuberculosis lesion. You can see the calcification in it,” he explained. “What are the four radiological densities, Faraz?”

Dr Faraz didn’t say anything.

“Radiology,” the Professor said smiling, “is the science of shadows. All objects have a density that attenuates oncoming radiation. What are the four radiological densities you can see on a chest X-ray?”

“Bone?” Dr Faraz ventured.

“Yes, good. And what else?”

“Air?”

“Yes, air, water, bone and metal.” Professor Clouseau summed up. “Whenever you see a lesion, ask yourself what density it corresponds to and you will be able to identify it more easily.”

We smiled. He made it sound so easy.

“Alright, on to the next patient.”

It was a long round. Twenty five patients on the ward and ten to fifteen minutes on each patient. Three hours hours later we were all exhausted as the Professor relieved us to run our patients’ orders. I went back to the nursing counter to help Dr Salman with a discharge summary. Dr Faraz came over.

“What are you doing for lunch?” he asked.

“Going home,” I teased.

“Ah, yes,” he said dolefully.

An attendant came up to us.

“Excuse me, doctor sahib?” he addressed Dr Faraz.

“Yes?”

He handed over two packs of intravenous antibiotics. They were the foreign, expensive kind.

“My mother passed away this morning. She doesn’t need these any more. If you could please give them to someone who needs them?” he said.

Dr Faraz looked at me.

“I think I know what to do with these,” he said, grinning.