Read Hope in Chains :: Blood

It was soon time to apply for his post-graduate entrance exam. General Surgery was a sought-after specialty, but with his grades, Suresh made it in his first attempt. This was how Suresh again found himself in Professor Madavan’s unit. It was a Thursday and they were in the theatre. The large multifocal dome light was shining down into the open abdomen. The intestines hung out to one side, revealing a large cyst arising from the head of the pancreas. They were one hour into the operation and Chief had just dissected off the lower surface of the tumour. Suddenly, the intern to his right, who was retracting the liver, disappeared from sight. They heard a dull thud and then a loud clang, as the large retractor fell to the floor and slid to a corner. Dr Madavan looked down to find his intern sprawled on the floor at his feet. “Remove him,” he commanded in a loud impassive tone before he turned his attention back to the tumour at hand. He had carefully dissected to some extent all around. He gently turned the mass down to get at the central bit of tissue that was holding it down. The next nip of his scissors saw a spurt of blood that hit the assistant’s face before Chief put a mop on it and then one more. “Arrange for blood,” he said gravely to his senior resident standing on the floor. He turned on the intern standing around and then sent him packing. “Go out and get some donors,” he yelled. The anaesthetist was in a flurry and sent her technician hurrying to the theatre blood storage unit. “Get some good suction ready,” he told his team as he gently peeled away the mops. No sooner had the last one been removed, the blood gushed out and began to rapidly fill up the abdomen. This time, he blindly reached into the red pool and with his thumb and finger, he clamped down on the site he thought was the cause of the problem. His left hand stayed there, while he looked blankly at the wall.

The blood that was up to his wrist had receded with the powerful suction on the job. Meanwhile, the anaesthetist was rapidly losing her cool. “Do something, Sir,” she told the surgeon anxiously. “He is dropping his blood pressure.” He glared at her over his spectacles, but said nothing. The field had become reasonably clear; whatever was bleeding was under Chief’s thumb. “Get me an artery,” he said as he stretched out his right palm to the scrub nurse. She handed him the usual medium artery forceps. He took one look at it before flinging it across the room to its furthest corner. “Where is Manjula?” he bellowed. “Why can’t they post her with me, at least on the majors?” Manjula was an older hand who had spent years assisting him. All this time, his left hand was firmly in control in the depth of the abdomen. He reached out once more and this time, he was given an instrument long enough to reach to the bottom of the abdomen. He rested a moment and then made sure the retractors and the suction were in their place but yet out of his way. While his left thumb and index finger gradually relaxed their hold, the slightly opened jaws of the forceps darted downwards to take their place, biting down on the tissue that held the bleeder. He made sure that the instrument was ratcheted safely up to the third notch before gingerly relaxing his hold on it. He gave a big sigh and looked up to smile at Shankar. “Now for some thick atraumatic silk on a round body,” he asked. “No hurry,” he added, knowing that the emergency was over.

Having got what he asked for, he checked its tensile strength by stretching the ligature with both hands and giving it a good tug. Satisfied, he put the needle back onto its holder and reached into the wound; he deftly directed the round body needle into the pancreatic tissue, making sure to encircle the area around the tip of the precious forceps that was holding things together. He took the ends of the suture in his finger and he directed the vector of the tension with an outstretched index finger. “Ready now?” he asked Shanker, who was holding the artery clamp. “When I tell you, release the clamp and get it out of the way.” After a few deep breaths, they were ready to go. “Yeh,” said his boss and Shanker released and withdrew the forceps in one fluid motion. At the same time, his boss tightened the ligature in a flash, with enough tension to singe down on the tissue but not too much so it cut through. Something that only the sensitive fingers of a surgeon could determine. He threw another knot on the first one to secure it, and then two more for safety. “Always leave an extra knot just in case your assistant decides to cut it too fine,” he commented, looking at Suresh. Then, holding his gloved right hand in front of him, he flexed his fingers and declared, “Shankar, you may be having all those new-fangled scopes and instruments coming. But mark my words. Nothing like these hands.”

The patient survived and so did the intern. The tender part of this great surgeon made its appearance after he had scrubbed off and gone to the professor’s lounge. Suddenly, he remembered his new intern who had taken a fall. He was soon seen carrying a cup of his own coffee to the junior doctor’s lounge and giving it to the poor chap. Tears ran down the young fellow’s face as Chief left the room. Sunithi had meanwhile gotten over the temporary setback and cleared medicine in the next attempt. She had sat and really worked hard for her entrance exams. She made it from being second on the waiting list to getting onto the diploma course in paediatrics. She had always liked children and this was what she wanted to specialise in.

She said a diploma would be enough to allow her to practice in most places. Suresh was pleased as long as she was happy. They got engaged at the beginning of Suresh’s final year. It was a small but elegant function, held in one of the finest hotels in Cochin. Sunithi’s diploma course being two years, they would pass out at about the same time. The wedding was slated for that time, about a year from this present function. Suresh could just about wrangle a few days for it. Suresh was lying on his own bed, while all these years tramped through his memory. Then another incident from those residency days came to mind. This time, the patient had not been so lucky. It happened during his one month posting in thoracic surgery. In that super-specialty unit, he was again at the bottom of the food chain (as Chief would have put it!). There were no interns and so he found himself doing first-call duty once again. And again at the mercy of the nurses who would call him up at any time of night and day—for an IV line gone sour or an order that had to be initialled. One theatre day, he was the third assistant on a patient in her late teens. She was a cheerful girl, who quickly made friends with her caregivers, including Suresh.

From her childhood, she had suffered repeated attacks of dyspnoea and could not run or play as other children did. She was diagnosed to have a PDA (patent ductus arteriosus), a defect that lay between her aorta and pulmonary artery. This conduit was useful inside her mother’s womb, but should have closed at birth with the expanding lung. In her case, it had remained open, shunting large quantities of blood through her lungs and putting her cardiopulmonary circulation under stress. The last time that Suresh saw her alive was during the previous day’s night-rounds. “Goodnight, doctor,” she had called out to him cheerily, her big circular earrings swinging as she shook her head from side to side. He was the last one to leave the ward among the doctors on duty. The next day, her chest lay open before them. The heart was pulsating under the pericardium, like some restless beast waiting to be released from its cage. Suresh was standing to one side, retracting on the lung. The surgeon had dissected into the mediastinum from one side. The aorta came into view, throbbing with the pressure that it drew directly from the body’s amazing pump. The blood that flowed through the great vessel at this point would have been enough to fill a bucket in a matter of minutes and the pressure enough to drive a fountain a metre and a half into the air. The ductus was dissected out, a loop of thick silk was passed under it and the knot was carefully fashioned. The operator was tightening down on the ligature when it happened. Suresh would never know exactly what went wrong. Perhaps the silk broke or his hand slipped. He only saw the surgeon’s elbow jerk awkwardly for a second. The next moment, the chest was filling up with blood at an alarming rate. Dr Saha frantically tried to stop the flow with his hands, blindly groping under a rising tide of crimson. “Satensky!” he cried out frantically and was immediately handed over the large instrument used to clamp large vessels. He closed down on something, which must have been the aorta, for the bleeding slowed down a bit but still kept coming. The red deluge filled the chest and spilled over the sides, drenching drapes and gowns on its way to the floor. Suresh found he was standing in a pool of blood with his feet soaked in the stuff. It was all over in about a minute. The monitors had thrown all their alarms and tracings were all flat.

The jerk of the knot, for whatever reason, had torn a hole in the aorta, pulmonary artery or maybe both. One of them might have been fatal, but if it were both, it was beyond help. They staunched the bleeding with mounds of mops, called on the pump technicians and put her on the heart-lung machine while her great vessels were repaired. After this, they shocked the heart back into action and it faithfully but feebly got back to work. The patient was braindead by now and on a ventilator. She was transferred to the ICU on a heavy dose of inotropes to keep her BP up. She died the next day, never having gained consciousness. The only thing worse that Suresh could think of was for her to have become a vegetable, like some patients he had seen. Dead yet alive; alive yet dead to all that mattered. What was life anyway? thought Suresh. Without choice, what was life? These living dead had no choices, not the smallest, tiniest choice. Unless… Unless the choices were made somewhere deep within them, and this we would never know. Even while they were working like dogs to save lives, death was always around the corner. Like the young mother in the burns unit, shrieking her way to an untimely delirious death, her bloodstream taken over by bacterial toxins. The most powerful antibiotics did nothing to save her. Then there was that patient with terminal cancer being sent home to die.

The man did not know his prognosis, for his relatives had refused to allow them to tell him he had only a few weeks to live. This being the case, he cheerfully bid Suresh goodbye in the usual Tamil greeting—Poyitu Varren. (I will go and come back.) Looking into his face, Suresh felt a tinge of sadness, for he knew that he would not see that old man again, nor would he ever come back. He also felt a little anger at his relatives. Like it so often happened, the relatives would not want to tell the sufferer the diagnosis of an incurable disease. I would certainly like to be told if I were the patient, Suresh remembered thinking during those times. He was thankful that he did not know then, how little it would take to go from being a doctor to being a patient. The last year of his surgical residency seemed to drag on and on. It was one of those nights again. His unit was on admission duty and when this came on top of a regular operation list, it was enough to exhaust even the toughest of them. And so Suresh found himself at 5 am, groggily entering the theatre yet another time. He had hardly slept over the last twenty-four hours, but he still had a few more hours to go before handing over his pager to the next guy at 7 am. The patient had come in at 1 am with a duodenal perforation. This should be an easy one, open and shut, he thought to himself as he tumbled into his theatre overalls. And so it was, except for a minor incident, which had been totally erased from his memory in a few days’ time. The patient was being prepped when he noticed that the patient was inordinately emaciated for a disease of such short duration.

Are all his other tests normal?” he asked the second call. Having gotten a ‘yes’ for an answer, he dismissed it from his mind without further thought. Suresh had finished sewing up the perforation with four bites taken across the small hole, adding a piece of omentum in-between to bolster the repair. He washed out the abdomen and thought he would just put in the drain before scrubbing off. The junior resident could do the rectus and the intern would probably get to do the skin. He had his left hand inside the abdomen, his index finger tenting up the skin at the point where he wanted the tube to exit.

The finger was protected by many layers of muscle and fascia. The scalpel that his right hand held was only expected to reach the subcutaneous tissue, the rest of it being achieved by a blunt hemostat. Whether the blade was unusually sharp or if he was in an inordinate hurry to finish, whichever way it was, the scalpel went right through the skin and several layers of muscle and fascia. Suresh felt a sharp pain as the knife point made contact with the tip of his finger. He yanked out his hand and held up his finger to examine it. The glove had been pierced and a touch of blood was visible beneath the ivory of the latex. He finished pulling the tube through with a curved Koker-clamp before scrubbing off. “Wash it with water and betadine,” advised the worried anaesthetist. It was a small wound, about 5mm in length and less than half that in depth. The bleeding had stopped. Somebody brought him some Band-Aid. He walked out of the theatre, looking forward to a few hours of sleep. He felt comfortable, except for a mild throbbing pain in his finger. It would take about a week to heal. He would have to tell his unit head, and this would mean no operating during this time. He was relieved in one way, as it would mean a few more hours of sleep and a little more time with his books. All this seemed so far away to Suresh, as he lay there in his own childhood room and on his own childhood bed. His long reverie had made him oblivious to time. He must have slept and dreamt some of it. He did not know. He was awake now. Later on, his mother would tell him that she had come up to call him for lunch, but found him so soundly asleep that she did not have to heart to wake him up.