6. In the shadows of a giant

It was one in the morning. I was woken up to attend to a young girl who had been bitten by an unknown animal 2 hours back. She had been in the field near her house when she was bitten on her hand.

The patient was unable to talk. There were multiple bite wounds on her left hand. She was having difficulty breathing and her eyelids were drooping. She was unable to move her hands and legs. All this seemed to indicate that she was suffering from neurotoxic envenomation (that is, she had most probably been bitten by a snake whose venom acts on the body’s nervous system). I requested the nurse to administer the test dose of anti-snake venom (ASV) and prepare an infusion of it. I also called my senior doctor and asked him to come over to see her.

By the time my senior arrived, the patient’s condition had worsened. She was gasping for breath, her oxygen saturation levels were dropping and her pupils were almost fully dilated and reacting poorly to light –– she was at Death’s door. While we started desperate resuscitation measures, my senior decided to request Dr. Bawaskar to come help us with the patient.

Dr. Himmatrao Bawaskar is one of the legends in the field of internal medicine. He has done immense research in various aspects of treatment of disorders in rural areas. He is world-renowned for his research in the treatment of scorpion stings & snake bites. His curt and professional manner may have not earned him many admirers, but his humility and willingness to help is the reason he holds such a high position in the medical fraternity.

Braving the early morning chill, Dr. Bawaskar arrived within minutes of receiving the call. He assessed the patient with a practised hand, asked me a few sharp questions and put forward his plan of management. With his experience guiding us, we simply followed his orders to the letter. The patient was put on mechanical ventilation in order to make sure her respiratory rate was being maintained. Apart from receiving a very large dose of ASV, multiple doses of medications like Neostigmine and Atropine and intravenous infusions of Calcium gluconate were administered –– in order to neutralize the effects of the snake venom.

At 4:30 am, the patient was finally stabilized. I was advised to monitor her vitals every half-hourly and to inform my senior if there was any drastic change in the parameters. Later in the day, she was transferred to a larger government hospital for intensive care & monitoring. Before her transfer, Dr. Bawaskar made sure that I put his contact number on the transfer letter, so that the attending physicians could discuss her further treatment with him. Due to his efforts, she recovered completely in two days.

Watching the passion with which an expert worked in his field motivated me to study harder and to keep my eyes and ears open. Because, as one of our professors told us in medical school–– what we learn today, no matter how trivial, could save somebody’s life tomorrow.

5. Labour Pains

Every time I hear an ambulance coming into the hospital, I subconsciously start chanting one prayer “God, please, let it be any patient – any illness known to man ­– but, please, not a pregnant woman in labour”. I will explain why I have come to fear pregnant women like the Plague.

Labor is the natural process of delivery of a baby. It is a complex mechanism, involving an excruciating amount of pain for a long time. We have been taught that the definition of “normal labour” is a retrospective term. This means that a delivery is termed a “normal delivery” only if certain criteria were fulfilled – the stages of labour took place within specific time periods, the baby was delivered with minimal aids, the mother adequately managed to prevent excessive bleeding and so on. I do not exaggerate when I state that there are innumerable problems that could occur.

I have immense respect for obstetricians-gynecologists (specialists in child-birth and the reproductive health of women), having seen them perform incredible feats in delivery rooms and operation theatres. But what is most commendable is their infinite patience, considering their tense work environments. There are people who believe that the birth process is like “poetry in motion” – the act of “one life giving rise to two”. I would request such philosophers to spend just half an hour in a delivery room.

A hospital’s labour room is filled to capacity at any given time. The atmosphere is hectic on a good day and Armageddon on the worst. During heavy shifts, the junior doctors usually move from one delivery table to the next, sometimes even without taking meal breaks. Most women are able to tolerate the process with minimal pain, but there are always a few who make your life miserable – that one person who delays till the last moment and then lands up at 3 am; and the low-pain-threshold patient, who (even though it is their second or third child) is screaming their lungs out, making first-time mothers nervous.

In rural health centres, the medical officer is solely in charge of the delivery and the health of both the mother and baby. This can be daunting for a number of reasons.

In any academic institute or major city hospital, you are always surrounded by people – senior doctors, colleagues and nurses. While examining a pregnant patient, there are times when you can’t figure out the position of the baby or where exactly the baby’s heart sounds are best heard. In such cases, you can just turn to the person next to you and ask them for help. They will curse you for adding to their workload and wasting their precious time, but they will always help clear your confusion. Now place yourself in a rural setup – with the closest doctor at least half an hour away – and you will realize the problems faced.

Also, in city hospitals, pediatricians and neonatologists (specialists in child health and newborn health respectively) can be called urgently in case a baby needs to be resuscitated. You do not have that luxury in a rural health centre, so the responsibility of resuscitation falls on you. That, as my colleagues will agree, can be a very scary scenario.

And then, as always, there are social and literacy problems. There was a patient who had delivered her sixth child after a painful, prolonged course of labour. Later, I tried to explain to the patient and her relatives about the need for permanent sterilization. She replied, in a supremely confident manner, that she does not require it as she will not get her regular menstrual cycles for the next “two and a half years” (she seemed confident of the exact time). I have yet to come across any case where a healthy woman, with no prior medical history whatsoever, can predict something like that. I will not be surprised if she comes pregnant a seventh time.

There was also one incident I will never forget – a woman, having two healthy beautiful daughters, came pregnant again because the family wanted a male child. When the child was born – a girl, as Luck/Fate/Destiny would have it – the female relative in the delivery room mistook her for a boy. She happily announced it to the third-time father and he – to my amazement – bowed down to the child, touching his head to her feet. The nurse immediately pointed out the relative’s mistake and the smile on the father’s face instantly disappeared – it was as though we had told him that the child was still-born. He later apologized for his behaviour and promised to take good care of the girl.

Thus, the delivery of a baby is never easy, but like so many things in life, one gets better only with practice. And there are very few experiences that can be more heartening than hearing a newborn cry.

But “poetry in motion” ? No, thank you, I do not think so.

4. My First Post-Mortem (P.M.)

When one mentions the words “Forensic medicine and toxicology”, the mind conjures up images we have seen in movies or television shows such as CSI – Crime Scene Investigation (the popular American show). One thinks of good-looking scientists, in clean high–tech labs, scanning a body meticulously with handheld lamps. They are shown using many chemicals to find that strand of hair under one fingernail that helps identify the murderer. However, during medical school, we saw the realities of the field and all romantic notions were effortlessly dispelled.

In any government hospital, the forensic medicine department and its adjoining morgue is located in one corner of the hospital campus. The entrance is usually adorned with pictures of the local gods, in an effort to enlighten the gloomy atmosphere. It is a desolate place, visited only by grieving relatives, overworked policemen and the hospital staff.

To their credit, the doctors and support staff work as efficiently as possible to clear the backlog. But due to the continuous workload, the legal paperwork involved and the perennial staff shortage, even a 24-hour shift is inadequate. As a result, the storage cabinets are almost always filled to capacity. And I will not even try to describe the smell – it is something that will make you immune to all noxious odors for the rest of your life.

Our only contact with the department was during academic activities (lectures, exams) and when we had to record 10 post-mortem examinations in our journals. We dutifully avoided any active participation in the subject and so, even after passing the exams, our practical knowledge was extremely limited.

One of the duties of a medical officer is to perform the post-mortem examinations of the deceased people who lived in the surrounding areas – the areas that fall under the jurisdiction of the health center. And, so, on the fifth day of my posting at Poladpur, I was assigned my first post-mortem. It had been an accident case and involved a young girl. It was mentioned in the local newspapers for a few days thereafter, but I cannot divulge the exact details. The experience, however, was enlightening.

We conducted the post-mortem in the evening. As per the law, we began only after receiving the inquest report of the local police and their request letter. The post-mortem room of the hospital, as expected, was located far away from the hospital building. One of the hospital staff, a veteran in these procedures, assisted me. We started by noting the clothes and ornaments worn and any identification marks (tattoos, birth marks). I then looked for external injuries, after which we examined the body internally and noted our findings. We then handed the ornaments back to the relatives and sutured what had been cut so that it would be presentable. The entire process took one hour but it felt much, much longer.

Needless to say, I did not sleep well that night. I kept replaying the entire scenario, wondering about the young girl and her parents – another life cruelly cut short, all their hopes and dreams shattered. But there was indeed a silver lining. As doctors, in spite of everything we are trained for, we still feel our patient’s emotions – pain, grief or joy. It shows that we are still human - and that definitely is not a bad thing.

3. A lesson in Humility

I remember my first day of medical school as though it were yesterday. There were 200 of us packed in a lecture hall – fresh-faced teenagers, unsure of what lay ahead. And, in the first 2 hours of our medical careers, we were congratulated by the senior faculty for having been enrolled into one of the top academic institutes in the state. We were informed that we were on the enlightened path of becoming medical doctors, who would be shining examples in society. Although the faculty meant well and hoped to instill a sense of responsibility, it did not help us keep our feet on the ground. My colleagues from other medical colleges confirmed that this was the usual pattern of “orientation lectures”, year after year.

Medicine, as is well known, is one of the longest and toughest fields of academics. During the process, we slowly but surely tend to become less human. The emotional detachment helps us function rationally, but it sometimes produces a sense of infallibility and an egoistic nature. This display of superiority is clearly evident in the attitude of a doctor towards his/her junior colleagues, the hospital staff and patients. And I would be lying if I said that their attitude did not rub on to us (I would like to meet a single medical student who does not agree with me on these two points).

By the time we were finished with medical school, we all believed (in at least some small measure) that we were prepared to face the world on our own. A few days in Poladpur made me realize how wrong I was.

In India, we have two broad categories of medical doctors – firstly, the MBBS & MD/MS degree holders (the “allopathic” doctors), who are authorized to prescribe regular medications. The others are those trained in alternative medicinal sciences – clubbed under the category of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, Tibi, Homeopathy). The AYUSH doctors actually form the major backbone of the rural health services, where allopathic doctors are short-staffed.

Recently, the state government announced that the AYUSH doctors should receive a one year training course in Pharmacology (the science of medications – their mechanisms, uses and side-effects), so that they would be able to serve the rural population better. This was met by stiff opposition from the allopathic medical fraternity, who felt that this “magic bullet” solution would not solve the long-term inadequacies. The topic has been debated by far more experienced people and I would not like to go into the details, but like others, I too believed that this move would not be in our best interests.

What I learnt in my initial days of the rural posting was a simple yet much-needed lesson – a MBBS degree and a “doctor” tag does not make a person intellectually superior to an AYUSH practitioner or a staff nurse. It is clinical experience - and experience alone - that makes all the difference. The AYUSH doctors have conducted multiple deliveries, performed innumerable wound repairs and being a part of the community for many years, have a deeper understanding of the patient psyche. This helped me bridge the communication gap with my patients during my initial days.

The staff nurses have decades of practical knowledge and have worked with many senior doctors, so their inputs to problems were always valuable. Most of the nurses I have worked with were extremely helpful, knowing that we have yet not faced real crises situations. Learning from them has been a humbling & enriching experience, something that I did not get a chance to experience during medical school.

A quote from the Christopher Nolan directed movie Batman Begins is sufficient to sum up what I have to say – “It’s not who you are underneath, but what you do that defines you”.

2. Rural India - a different country ?

Doctors who have graduated from government medical colleges in Maharashtra (and some other states as well) have to undergo a 1 year posting in a rural area of the state. This is done to recover the subsidized fees of our course in medical college. A doctor can be assigned as a Medical Officer in a hospital or health centre in any part of the state, as per the vacancies.

This blog is about my personal experience as a medical officer at a rural hospital in a village in Maharashtra.

The village of Poladpur is located in Raigad district of Maharashtra, with a population of 5000-15,000. There is a Wikipedia link that talks about the town and its surroundings. The National Highway No. 17 forms the main street of the village. It is en-route to the popular tourist destinations of Mahabaleshwar and Goa, so it receives a lot of vehicular traffic. The main language spoken is Marathi and a number of its Konkani dialects and the main occupation of the people is agriculture. 

Main village square

National Highway No. 17

Like the rest of the state, the surroundings of the village are breathtaking. It lies between the mountains of the Sahyadri range and thus experiences extremes of temperatures – heavy rainfall during the monsoons, hot summers and chilly winters.

House on the village outskirts

Village farms

The Rural hospital of Poladpur was to be my first posting as a Medical officer.

Like a lot of my colleagues, I was brought up and educated in a sheltered city atmosphere.  My exposure to rural life had been limited to short holidays and what I had seen in Indian movies, so this was to be a major lifestyle change. What I was not prepared for was the realization that I may have been living in a different country till now.

There is a very simple way of life followed. People greet you with a genuine smile on their faces. They are willing to go out of their way to help you. They are untouched by the world’s events, seemingly content in doing their daily work and being involved in their community’s welfare. Festivals are celebrated with devotion and fervour, without any false pretense or vulgar display of wealth. This village may only be 200 kilometres (125 miles) away from the city of Mumbai, but figuratively it is a world away.

But you can never be too far from the ugly face of human nature. One tends to hear about the local superstitious beliefs, about how the local politics unnecessarily interferes in your work. You see the effects of unqualified “quacks” offering “treatments” to gullible and desperate people. And you realize how difficult it is to change age-old traditions and beliefs. One glaring example that comes to mind is the desire for male children – the staff nurses at our hospital were worried that if there were too many female children delivered at the hospital, pregnant patients and their families would consciously start avoiding it.

This posting was going to be challenging in more ways than one. And I hoped that I would be up to it.

1. How to apply for the Maharashtra MBBS rural bond (Technical details)

Doctors who have graduated from government medical colleges in Maharashtra (and some other states as well) have to undergo a 1 year posting in a rural area of the state. This is done to recover the subsidized fees of our course in medical college. A doctor can be assigned as a Medical Officer in a hospital or health centre in any part of the state, as per the vacancies.

This blog is about my personal experience as a medical officer at a rural hospital in a village in Maharashtra.

My first post is about how one should apply for this rural bond because frankly, the application process is very confusing & opaque. I had to rely on my seniors and their feedback as to how to go about it.

This post will be technical and uninteresting for a non-medical person, but I hope it helps somebody who is trapped in the application maze.

So here is what needs to be done if you wish to apply for a rural posting (The information is up-to-date as of October 2014).

1. Go to Directorate of Health Services (DHS - Arogya Bhavan) office – in the St. George Hospital campus, next to Chhatrapati Shivaji Terminus railway station. On the 5^th floor, ask for the staff who are in charge of the rural bond allotment. They will ask you to write an application (in Marathi), simply stating where you wish to apply for the bond. You have a choice in applying to certain “circles” / “areas” where you wish to take up a posting (this is actually the only choice you will get in the entire application procedure) – you will understand more about this when you go through the application process.

Along with this, you need to submit the following documents (attested xerox copies):

(a) MBBS Passing certificate

(b) MBBS Internship completion certificate

(c) Permanent Maharashtra Medical Council (MMC) Registration Certificate OR

Temporary Maharashtra Medical Council (MMC) Registration Certificate with a copy of the receipt of Permanent MMC Registration.

2. You then have to wait till the application goes through (which would take two weeks usually). The other option would be to go to the office of the Deputy Directorate of Health Services (DDHS – Upasanchalak Arogya Bhavan), where you had applied, after a week of your application.

You have to fill up a form and attach the following attested xerox copies:

(a) 1^st, 2^nd , 3^rd MBBS (Part 1 & Part 2) marksheets

(b) Attempt certificate

(c) MBBS passing Certificate

(d) Internship completion certificate

(e) MBBS Degree certificate OR if you have applied for your degree but haven’t got it yet – a copy of the MBBS degree form and its supporting documents.

(f) Permanent Maharashtra Medical Council (MMC) Registration Certificate OR

Temporary Maharashtra Medical Council (MMC) Registration Certificate with a copy of the receipt of Permanent MMC Registration.

(g) Age Certificate – an attested copy of the first & last pages of your passport will also do.

(h) Caste Certificate with Validity (if applicable)

(i) Previous experience certificate (if applicable)

Make sure you carry all the original documents as well (they are cross-checked at the time of application).

3. After a variable period of time, you are called on the contact numbers you have provided and informed that your posting order has been created.

You then have to go to the respective DDHS Office again. You must submit a hand-written Affidavit, in Marathi, on a 100 Rupees stamp-paper (which you must carry with you) stating that you will not make any claim over a permanent job. After this, you are given your posting order.

After receiving your posting order, you must report to the Civil hospital of the particular district to which you have been assigned. This must be done within 7 days of receiving the posting order.

4. At the Civil Hospital, you submit an application to the Civil Surgeon, stating your wish to join the health centre you have been assigned. Along with this, you attach attested copies of the same documents that you had submitted at the DDHS Office.

If you have not received the Permanent MMC Registration till now, you must give an application on a 50 or 100 Rupees stamp-paper, stating that you will submit your Permanent Registration Certificate to the civil hospital within 30 days of joining the health centre or your first salary will be delayed.

After this, you are given your final Joining Order and asked to report to the health centre you have been assigned. Although there is no specified time-frame for this, I have heard that this must be done within 7 days of receiving the report.