Read Hope in Chains :: The Hill People’s Hospital

The Hill People’s Hospital was built on a hillside that overlooked the Pachalur village. The road to the campus led steeply up from the village, past the forest guesthouse and took a sharp bend to reach the gates of the hospital. About twenty yards from the gate, broad stone steps brought you up to the OPD lobby. As Dr Ravikumar had humorously observed from time to time, “Any patient who can take those steps need have no fear about his cardiac fitness.” A further forty yards away, as the road reached the level of the hospital buildings, a short branch to the left allowed vehicles to bring sick patients directly to the wards. To the right of the stone steps, a small terraced garden sported some zinnias and a few rose bushes. From the top of the steps, you could look down south onto the Pachalur village, its dark brown roofs arranged close together like biscuits in a tray. In its northern extent, the campus spread all the way up the slope, spilt over the ridge and occupied a flat acre and a half that accommodated most of the staff quarters. After this, the land fell away steeply into the Parapalar valley. Most of the buildings had tin roofs and whitewashed brick walls, except the two doctors’ quarters in the eastern corner of this small plateau. These had granite walls, because they had been on the property even before the Hill Tribe Society had acquired it.

Dr Suresh was happy to be staying in one of them, the one further out. It had such a beautiful view over the Parapalar valley, the lake and out onto the vast plains beyond. Dr Suresh had joined the staff of the hospital five months ago and now was very much a part of the team. People did not know much about him, but they guessed he must have been about 31 or 32. Their guess was right, for Dr Suresh had his 31st birthday soon after he joined the hospital and now he was running 32. His skin was fair, the colour of light sandalwood. His scalp held a full complement of lush thick black hair, which made him look younger than he was. Slim without being thin, his face was sincere, yet the Roman nose, square jaws and piercing light brown eyes gave it great strength. Almost 5’9” tall, Suresh carried himself well. Before the hospital came up on this five-acre piece of property, it had been sparsely wooded. Silk cotton trees grew in plenty, interspaced with lime trees and patches of coffee. In fact, two of the coffee plants had survived the change and could still be seen just after you passed the main gate of the hospital, one on each side. There they stood like sentries, their fat sinuous trunks corkscrewed and gnarled with age. When he saw them, Suresh had more than once caught himself thinking that they would have made such wonderful lampstands. The property had belonged to Ratanavadivel, a wealthy contractor. There was a story behind how the Hill People’s Hospital came to own the land; a story that Suresh did not know as yet. Suresh glanced across the chicken-wire partition that separated the OPD from the small foyer of the hospital and the medical records department. Judging by the queue at the counter, it would be a busy Monday.

He had to finish the first lot of patients waiting for him. This done, he got up to go to the wards for rounds. As he left his table and turned into the corridor, a cheery voice called after him. “Sar, Sar!” He stopped and spun around to see who was calling. The man hurried up to him and now stood respectfully before him with a beaming face. With both his hands, Marimuthu caught hold of his doctor’s right hand and shook it. “How are you, Sar? How is everything? You will come back to the OPD, won’t you?” “Yes, I will,” Suresh answered him reassuringly. As he walked back down the corridor, Suresh recalled that Wednesday morning about a month back when he had first set eyes on Marimuthu. Early one cold November morning, at a call from casualty, Suresh had reluctantly gotten into his clothes, put on a jerkin and trudged his way to the hospital. Marimuthu had been brought in at 5:45 am. He was stretched out on one of the two beds in the room. His breathing was laboured, his anxious eyes were barely visible under drooping lids. He could hardly speak. The relatives informed Suresh that about half an hour ago, he had told them that he was bitten by a snake on his left foot. Suresh walked to the end of the bed and bent down over his foot to locate the tell-tale twin fang marks that characterised a venomous bite. He had just located it when he realised that something was wrong. Marimuthu had stopped breathing at least a minute ago, and now his eyes rolled up ominously; his oxygen-starved brain fired away at random, sending his limbs into decerebrate rigidity. Suresh berated himself for not having acted earlier. Surely, this was a cobra bite—the difficulty in breathing, the drooping eyelids, lack of local swelling—it was all there in plain sight. The neurotoxin was well on its way. He should have gotten ready for assisted breathing earlier, instead of taking a slow history and searching for bite marks. “Mask and Ambu!” he shouted as he ran to the head end of the patient. He bent the neck back and supported the patient’s jaw, pulling it forwards.

The single nurse on duty was taking too many precious moments to find the mask and Suresh shouted again, this time for a laryngoscope. He thought of mouth to mouth resuscitation, but he knew he could not because of his problem. But even if he could, he probably would not have put his lips to Marimuthu’s dirty foul-smelling, frothing mouth. At last, the mask and Ambu-Bag arrived; the mask was a little big but it would have to do. He clamped it over the patient’s nose and mouth, supported the jaw with his little fingers and tilted the head back a little, asking a bystander to press the bag. Meanwhile, two other nurses from the wards had come on the scene. Suresh told one to hook up an IV line and the other to attach an ECG monitor. Suresh again called out for an endotracheal tube and a laryngoscope. It finally arrived. Hope the batteries are alive and the light working, he thought as he removed the mask. “Ready for intubation?” he bawled over the clatter of running feet and wailing relatives. With his left hand, he introduced the blade of the instrument, clicked it in place behind the tongue and lifted the epiglottis forwards. The lights worked fine, he noted with relief.

He could see the posterior end of the vocal cords. With his other hand, he grabbed the tube but without a stylet, it was pliable and could not be directed adequately. “Stylet, stylet!” he yelled. “Will anybody offer an endotracheal tube without a stylet?” he added angrily. He clamped the mask back onto the patient’s face and prayed as the nurse frantically searched for the stylet. The bystander was faithfully pumping the bag. The doctor noticed that the chest was moving, but only slightly; clearly the ventilation was not adequate. Air was leaking around the illfitting mask and a good part of it seemed to be going into the stomach, which was bloating up dangerously. If the contents of the stomach should decide to come up into the larynx, the game would have been as good as lost. The vomit would have drowned him, and if he escaped that fate, the acid stomach content would have ruined his lungs. Finally, the endotracheal tube with the stylet was handed to him; with difficulty, he manoeuvred the tube between the cords. Straightening himself slightly, he removed the stylet and connected the Ambu-Bag to the tube and asked the bystander to resume bagging. Suresh noted with satisfaction that the chest was heaving up nicely with each volley of air. Meanwhile, the steady beep of the ECG machine that somebody had hooked up showed him that the heart was still ticking away, but at a dangerously slow rate. He called for an ampoule of atropine and some sodabicarb. All this time, the doctor’s left hand securely held the tube to the patient’s mouth. He asked a nurse—now there were quite a few of them around—to connect the earpieces of a stethoscope to his ears; his right hand held the chest piece to the ribs first on the left side, then on the other. At each stroke of the Ambu-Bag, he was glad to hear the whoosh of air equally well on both sides.

He fastened the tube to the patient’s face with tape before he finally let go of it. At long last, both his hands were free. He straightened up fully, took a deep breath and stretched his shoulders back a few times. Now to assess the damage, he thought, as he bent down once again. This time, he used the laryngoscope like a torch, shining it into the patient’s eyes. The pupils constricted reflexively as the light hit the eye. The brain was not too badly damaged, he reckoned. But we would never know until the patient started talking. The brain was always the worry, the one with the least tolerance to anoxia. Shut off its oxygen for more than five minutes and it could be damaged forever;

on the other hand, the limbs could go without oxygen for half an hour and still bounce back with nothing to show for the insult. He looked at the ECG; the rhythm had picked up and his blood pressure seemed to be holding. Now it was only a question of maintaining ventilation till his own breathing revived. They had no ventilator machine so the nurses would have to take it in turns to bag him for however long it took to get him out. The cobra venom acted like the paralysing poison, curare. Therefore, in addition to a bolus dose of anti-venom, they gave the patient titrated doses of Neostigmine, which would hopefully antagonise the curare-like action on the neuromuscular junctions and shorten the period of respiratory paralysis. By this time, somebody had carried the news to Dr Ravikumar who arrived to find casualty turned into a sort of ICU.

He was happy at this, because they had no regular ICU. This is how it would have to be, he thought to himself, at least for now. Dr Ravikumar was a few years his senior in college, and he was the one who had started the work and founded the hospital. “Cobra,” Suresh said, looking down at the patient. “Umm,” replied Ravikumar. “Cobras are rare. Usually, it’s a viper. You see, cobras are fast, they usually get out of the way before an unknowing foot steps on them. Good job, Suresh!” he added. The patient suddenly became restless, his heart rate shot up, he was fighting the tube. It was clear that he would not tolerate the tube without sedation. In went an ampoule of morphine and another of diazepam via the IV line that was already in place. The drugs would hit the brain in five seconds. Within half a minute, Marimuthu had become quiet, his heart rate settled down to a steady 76. A roster was drawn up, which helped the nurses take turns at keeping his ventilation going. Later that evening, he had started breathing on his own. The Ambu-Bag was disconnected but the tube stayed until the next morning. The next morning, even the tube was removed and he was now being seen on rounds. Marimuthu was drifting back to consciousness one more time; he saw the face of Dr Suresh and his team looking down at him. He knew he was in hospital but did not know how long he had been there. His thoughts went back to the day when he had gone out to relieve himself in the dim light of early dawn. He had stepped on something and immediately jerked his foot back involuntarily as a stab of pain shot up through his leg. Must be a nasty big thorn, he thought to himself as he grimaced, stood on one leg and pulled up the other. He looked down to see what it was and it was then that he spied the creature out of the corner of his eye. The four-foot cobra slithered noiselessly over the grass and disappeared into the undergrowth. As things turned out, Marimuthu walked out of the hospital three days later. He was a coolie and much of the bill that stood against him was written off. After having come so close to the brink, he had a full life ahead of him. All he had to show for his ordeal was a tiny scar on his leg and the memory of a good deal of kindness received from Dr Ravikumar and his team.

This whole episode ran through Suresh’s mind by the time he reached the surgical ward. He examined the young woman on whom he had done an appendicectomy over the weekend. She had done well and was tolerating fluids; her IV line could now be taken off. The lunch break was short that day. Usually, OPD finished by about 5 pm but today, it was past 6 pm when the last patient was seen.

Suresh took the small path behind the hospital that led him to the dirt road. This road came in at the main gate of the hospital, lay in front of it and then skirted it around its eastern border. The small path that Suresh was now taking would join the road at this bend. On the other side of the road was a grove of eucalyptus trees, beyond which lay the fence. Dr Ravikumar’s residence could be seen about a hundred yards away to the left as Suresh was now walking past the driveway that led to it. Just before the ridge, another branch turned left and lead to a row of staff houses. Beyond the ridge, the road lay flat, narrowed considerably and came to an end at the base of a huge old pine tree on one side of which was the path that led to a wicket gate, and then the doctors’ quarters, which was Suresh’s residence. Suresh’s accommodation was luxurious, compared to what Dr Ravikumar had gotten when he first came to Pachalur 6 years ago. A social worker had told the young medical graduate about how backward the place was. He also heard about the exploitation of the tribals at the hands of the plains people. Dr Ravikumar had come on a reconnaissance tour and knew that this was the place that needed him. He looked around for accommodation for a whole day with little success. Most of the houses in the poor (untouchable) part of the village were little more than hovels with mud walls and thatched roofs.