Tuesday, April 28, 2009

My gifted, soft hearted Grand Nieces - II

A medical student's first experience of a liver transplant

Now comes my other grand niece, Apparna Jr. She is a bit tomboy-like. My niece is settled abroad and so her daughter, had her education over there. She is a medical student now in a premium college. She was a player in the college's girls' hockey team. Once, in an inter-college match, the boys' team had shortage of one player and she was asked to join. She was the lone girl player and they won the match!

I used to ask her to email me about her experiences in the hospital. She has got a flair in writing to the point. Her soft, compassionate nature, which is very important for a doctor is clearly visible here in her article. She has written her true feelings, without any colourful additions.

My transition II

I had a unique experience in theatres a couple of months ago, watching a liver transplant. It’s something I have wanted to write about for a while, but revision, exams and…well, life…got in the way.

Chapter 1: the mayhem of Hospital corridors

If you want to know what life in a hospital is like, just stand in the corridors. Here, you observe the unwritten hierarchy in splendid clarity. Consultants and senior registrars stroll at a leisurely pace, decked in crisp suits with stethoscopes swinging from their necks jocularly. Each glides smoothly with the confidence (bordering on arrogance) of one who has truly earned it - from spending many years as a quasi-slave to the hospital/college, methodically berated, demeaned and humiliated by superiors in days gone by. And now here they are, at the top of their field. Somehow, they manage to give the impression that they are discussing matters of great importance, when in fact they are clearly talking about last week’s game of golf, or who should win Wimbledon.

In between, you see the junior doctors (house officers) scuttling around, each with seemingly innumerable tasks to complete. Chasing CT scans, taking bloods, clerking patients , sending radiology request forms…it is easy to see why house officers refer to themselves as “the dog’s body”. It is 8 in the morning - one of the juniors has just finished his on-call shift and looks like death warmed up. Another one is holding about 40 patient files in her hands – it looks as though she’s about to topple over, and suddenly, her bleep goes off. Code red : there’s a cardiac arrest in A&E. And so the day begins.

Bleeding patients, emergency laparotomies, multiple stab wounds. The first doctors these patients encounter are the house officers… i.e. this will be my job in less than 2 years time.

But back to the corridor: nurses march around in their blue uniforms, sharply eyeing everything we do. They’re a strange breed, nurses! Some of them are wonderful, and help you more than doctors do, yet others seem to exist for the opportunity to chastise. Life as a medical student, whilst exciting, is also difficult because it is an exercise in continual humiliation. Undeniably, we are at the bottom of the pile. And it seems the nurses use our transient inferiority to their advantage, by unmercifully ordering us around, refusing to let us look at the patient files, and treating us as though we are as useful as a spoon.

And whilst you are standing in the corridor gaping at the sheer chaos of it, make sure you’re not in the middle, because you will be crushed by the porters wielding stretchers through the mayhem. The porters’ job is manual: they are huge guys, moving large pieces of equipment from one part of the hospital to the other. They exert their authority by size; the whole corridor’s population must make way when they trudge through, demanding space – from senior consultant to first year medical student.

Midwives, physiotherapists, technicians….and of course, the patients themselves, also populate this enormous corridor, to the extent that it really is a microcosm of the whole hospital. If you stand to one side and simply observe, the amount of human interaction you see is incredible. Facial expressions, snippets of different conversations, emotions fleeting across faces in just milliseconds – delight, confusion, annoyance, anger, humour, laughter etc. You slowly begin to realise how many people a hospital needs to make everything work, and just how important it is to be part of a team. Doctors cannot survive without the nurses, physiotherapists, lab technicians and porters. And patients cannot either. It serves to remind me that I enjoy this atmosphere of camaraderie, despite the long hours and relentless pressure to continually improve. Different people have different incentives for working in medicine. But at moments like these, it is like a united force brought together for the sole purpose of making a difference to the lives of others.

Chapter 2: Liver transplant theatres

Transplant theatres are on the second floor of the Hospital, tucked away behind the torrential swarms of people rushing around, through,(and sometimes on top of) each other in the corridors, each absorbed in their own quest to get a job done.

And here, in theatres, we meet a new breed of doctor – the surgeon. Often stereotyped as rich, arrogant and less intelligent than physicians, most surgeons are in fact approachable and friendly, especially if you take an interest in their field. The arrogance demonstrated by a tiny minority is sometimes painfully obvious, as some surgeons still stride into theatres like knights on horseback, and yell orders with a disdainful and contemptuous glance at their “subordinates”.

I stumbled into transplant theatres one dusky Thursday afternoon in June, feeling tired at 4pm but enthusiastic at the prospect of seeing my first transplant. The anaesthetist summoned me over to watch the induction of general anaesthetic and subsequent monitoring of the patient. As I chatted to him about liver physiology, the patient was wheeled in. I turned around, and saw, to my surprise, that she was an 11 year old child - small for her age and almost lost in the mountain of white sheets and dressing robes swathing the bed. She looked mildly apprehensive but not frightened, and was able to smile at us and the nurses.

I had no idea that this was a paediatric transplant list, and a wave of sadness hit me with full force, seeing such a young child needing a major operation like this. To a certain extent in medicine, we learn to constrain our emotions - it is a necessity, in order to survive in a place where death and suffering are ever-present. Four years ago, the thought of a patient with a heart attack would have upset me a great deal, but in medical school, we are trained to think about immediate diagnosis, investigations and management. We try to empathise with the patient’s pain and fears of the family. But if we allow ourselves to become too emotionally involved with every patient that we see, it ultimately becomes detrimental to both the patient and to the doctor.

However, there are situations like this, which cannot help but elicit an overwhelming feeling of injustice from within me. So many people are born with perfectly healthy livers, which they then go on to destroy by drinking vast quantities of alcohol over many years. It seems so unfair that others, like this child, are born with malfunctioning livers, and must suffer through no fault of their own.

I ventured over to the desk in theatre, to read the patient’s notes. This poor child has a condition called “familial intrahepatic cholestasis”, which is an inherited disease of the bile ducts within liver tissue. By the age of two, she had irreversible liver failure and required a transplant. Now, at the age of 11, the transplanted liver has also failed, and she needs yet another healthy liver. The consequences of a chronic illness like this are many and varied. The child is small, her fingers clubbed, her abdomen distended and her entire body is jaundiced and bruised.

She looks tired, and from her notes I read that she is academically behind other kids her age. I flick through page after page in the notes, and find that my throat dries up as I read that her father has deserted her; that she lives in damp squalor with her mother and 3 other siblings; and that her mother works relentlessly as an eyebrow-plucker in a rancid beauty parlour in order to support her family. Their income is minimal, and I am devastated beyond words to find that such misfortune can hit a family who have nothing to begin with. I find myself humbled, wondering how they must survive, from day to day, with the meagre earnings of a beauty parlour assistant.

I turn around and watch the child speaking happily to the anaesthetist as he explains to her why he needs to put an oxygen mask on.

“Is this what the doctors did when I was a baby?” She asks

“Exactly what they would have done, yes. And do you know where your liver is?” he asks . She smiles and points to the right side of her upper abdomen.

“Very good”, the anaesthetist is encouraging “we’ll make a doctor out of you yet!”.

He gives her a choice of flavouring (strawberry or chocolate) for the mask with which she will be put to sleep. She chooses strawberry, and settles down looking remarkably calm. As the mask looms over her face, and the anaesthetist tells her to “imagine going somewhere nice”, she shoots me a glance, so I try to smile encouragingly, and give her two thumbs up. The gas that flows through the mask makes her drowsy, her eyes lose focus and within seconds she is asleep.

Now the work really commences. Firstly, the patient is incubated and an arterial line is placed in her left arm (inserted into the radial artery). This is a painful procedure, so it is best attempted with the patient asleep! With the patient incubated, the ECG leads attached, the pulse oximeter clipped over her right index finger, and a urinary catheter in place, the next task is to insert a wire into the jugular vein of her neck, which is guided down into one of the chambers of the heart to monitor central venous pressure. At this point, I should mention that there were at least 3 anaesthetists and 7 surgeons present at the operation, reflecting its magnitude, novelty and the immense expertise required for success.

After what seemed like an age, the patient is finally prepped for surgery. The consultant surgeon, along with his registrars and house officers, walks calmly through the double doors. He is one of the foremost transplant surgeons in the country, perhaps even the world. He takes one look at my name badge and casually raises an eyebrow,

“You’re from Madras”…it was not a question.

“Yes, Doctor. My father went to MMC” I muttered, not quite knowing what he wanted me to say.

“I was at Stanley myself…are you interested in surgery?”

“Very much so.”

“Come over here…you can watch the operation from over my shoulder”. He brought a stool and made me stand behind him as he made the first incision. Being from Madras put me in his good books!

As with many operations, much of the initial part is done by the junior doctors: opening the skin, gently slicing through subcutaneous tissue with a diathermy instrument, isolating the intricate anatomy of the liver with exquisite skill. For perhaps 45 minutes, everything is going smoothly. Junior doctors swam in and out of theatre, pushing me aside to enhance their view of this holy grail of surgery.

I begin to chat to a fellow medical student, impressed by the smoothness of the procedure so far, but also bored by the languid nature of my passivity. At this stage, I can only observe: a medical student cannot actively participate in the operation. With a multitude of doctors blocking my view, the atmosphere slowly becomes hum-drum, even stagnant… and my thoughts float elsewhere.

CRASH! I am brought violently back to earth by the fierce whip of a voice cutting through the air. The voice is filled with anger, panic and desperation...”YOU IDIOTS!!!!!!!!”

I wheel sharply around. The voice belongs to the anaesthetist, and he is screaming expletives at the two registrar surgeons who were operating at the time. “I TOLD YOU! I TOLD YOU SHE WAS LOSING BLOOD TOO QUICKLY! LOOK WHAT YOU’VE DONE!”.

Puzzled and slightly scared, my eyes took a few seconds to scan the room and assess the situation. The atmosphere had shifted suddenly to one of tension, anger and alarm. Anaesthetists and surgeons were shouting at each other, each barking orders with the fear of one who knows what is at stake. To my horror, I saw on the monitoring screen that the girl’s blood pressure had dropped, quite suddenly, to 28/16. My heart started throbbing furiously, uncontrollably in my chest. I froze, engulfed in shock and disbelief. Oh my God, I thought. Please don’t let her die, please don’t do this.

For a split second, I felt suspended from time; even from life. All sounds blurred into one; my vision too became hazy as the nightmare of this new reality came hurtling far too fast. The only clarity I could perceive was the acrid stench of fear emanating from every single person in the room - it lingered a while in my nostrils. As I took a deep breath, and forced myself into sensibility, I saw blood dripping from the patient’s mouth to the floor with a barely audible splash. The anaesthetist’s shoes were soon covered, and he looked up in horror and swore at this new discovery of an upper GI bleed.

“I NEED FRESH FROZEN PLASMA…NOW!” he screamed at a theatre assistant. Furiously, he and nurses were infusing bags of fluid into the child’s bloodstream, trying to replace all the blood that had been lost so fast….trying, in earnest, to save her life.

“FASTER! IT HAS TO GO IN FASTER!” the anaesthetist cried to the nurse in despair. The veins in his temples seemed to fill threateningly, and his cheeks were flushed an angry red.

“250 mls per minute, doctor…that’s the fastest we can replace fluid through the cannula”, replied the nurse, in a surprisingly calm voice that belied her trembling hands.

“AARRGH”, the anaesthetist clasped his head with both hands in exasperation, having replaced bag after bag of saline, blood and colloid solution, but to no avail.

For 20 minutes that seemed like an eternity, it was touch and go. This child’s life was hanging precariously on a knife edge. Blood was being lost from the girl’s body almost as rapidly as it was being replaced, and we watched in astonishment and sickening anticipation, waiting for the final crash that might signal death, but hoping against hope to see her blood pressure rise. And eventually, after the anaesthetist’s tireless efforts at replacing innumerable bags of fluid, we saw the signs we were hoping for. Tentatively at first, but then more strongly, she achieved a blood pressure capable of sustaining life…56/32, 78/48…finally the doctors and nurses sighed in relief as her blood pressure reached 117/68. And with them, I uncrossed my shaking fingers and breathed for what seemed like the first time. She would survive!

The rest of the operation went smoothly, although it was very long – lasting almost 7 hours. The donor liver was flown over from Jersey. One of the junior doctors told me that it had belonged to a 14-year old boy who committed suicide just days before. When I heard this, I could not suppress a feeling of nausea from deep within the pit of my stomach. Such a young person had killed himself! What is the world coming to? It seemed that I was trapped, and could not escape the truth that children suffer, just as much as adults do. The only salvation was seeing that his liver was being used to give this young girl a new lease on life.

The Doctor stitched the girl’s portal vein to that of the new liver, which had to be cut down to fit into her tiny abdomen. The absolute precision with which his fingers deftly manoeuvred to create such new plumbing was awe-inspiring to watch. Years of experience have enabled him to perform even this, one of the most technically challenging operations, with amazing agility and confidence. I found myself wondering whether someday I could be this good.

At 11pm, after the final stitches had been sewn and the patient handed over to recovery, I eventually dragged myself away from the theatre. Yawning, I removed my surgical scrubs and ventured to the on-call room. It had been a long and eventful night, and it seemed that I had experienced such a range of emotions in the last few hours that my head was exhausted from the sheer intensity of it all. Without further thought, I slumped onto the bed and fell asleep.

Chapter 3: the aftermath

Until that fateful day in theatres, I had never witnessed a surgical emergency. The entire experience forcibly re-evaluated some of my perceptions and gave me food for thought. Firstly, I began to respect anaesthetists a lot more. Glory and prestige have always been the domain of surgeons, to the extent that the anaesthetist in the background is all but forgotten. It is a classic case of jock and nerd. The surgeon is ever-popular, with praises heaped upon him. However, it is the anaesthetist who is the brains of the operation. It is the anaesthetist’s job to keep the patient alive, to have the mental capacity to juggle complex physiology and pharmacology at once, and most of all…to be able to think clearly under pressure. When the girl’s blood pressure was falling, the surgeons looked dumbfounded and embarrassingly useless…this was when the anaesthetist came into play. It was the anaesthetist and the nurses, who ultimately saved her. So that was that.

Secondly, it made me realize how crucially important it is for hospital staff to work as a team, co-operating simultaneously to ensure a sequence of unbroken events. Saving the child’s life required the combined efforts of anaesthetists, surgeons, nurses, theatre assistants and even other departments such as haematology, to ensure correct cross-match of blood to be made available for immediate dispatch to theatre. One delay or flaw in this process may have cost the child her life. I guess this illustrates one of the big stresses in medicine: we know that anything less than excellence is unacceptable. Which means the pressure is always on!

A few days later, after I had finished work in the hospital, it was about 7 o’clock in the evening. Before going home, I decided that I must visit the child on the ward, to see how she was doing. So I climbed three flights of stairs and arrived at the ward - a specialist paediatric ward for very sick children. After pacing the corridor several times, I found her room and knocked. A young-looking lady opened the door and smiled at me. The child’s mother. She was very pretty, but despite the smile I could see sorrow in her eyes, with an almost defeated look, as though she had spent many sleepless nights in anguish, worried about her child. I quickly introduced myself and she looked grateful to see me, telling me that I was welcome to come and chat to the girl.

I glanced over at the child, forcing myself to smile when in fact I felt tears welling in up in my eyes. She looked better, certainly the jaundice was gone, and in fact she was faring remarkably well for a child who had recently undergone a major operation….but she was still very ill. A urinary catheter was in place, and blood was oozing slightly from her dressing.

“Hello, my name is Apparna Jr. and I’m a medical student”, I said, with a friendly smile.

She looked happily at me, and although shy initially, soon began to ask me lots of questions about her operation. “ what did my liver look like?” she asked, her eyes wide and alight with curiosity. I tried to explain that her liver looked cirrhosed, but it’s a difficult concept to explain to an 11 year old. “Who gave me my new liver?” she asked.

“Well, it actually came from a boy!” I raised my eyebrows, trying to look comical. Obviously, I didn’t divulge the fact that he had killed himself.

“A boy! I have a boy’s liver? Haha, that’s weird” she began to giggle, and soon I found myself laughing along with her, swept up by her innocence despite the tragic origins of her new organ.

I stayed a while, chatting amicably to the mother and child. We talked of many things; about the operation, about school and about life in general.

“Do you know, when I went to school I asked my science teacher, about the liver and what it does…” began the girl “…but he always says “ I don’t know, I only know about the heart!” “ she pointed to her own heart, looking slightly forlorn.

“Well, “ I said, “ I’ll bet you know more than your teacher about what the liver does by now, don’t you?!”. She and her mother both laughed as she nodded her head in agreement. It was nice to see them both happy, despite the dire predicament they had somehow landed in.

After a short while, I made my apologies and said that I had to leave. “It was lovely to meet you, “ I smiled to the child and shook her hand. I also shook hands with the mother, who thanked me for coming.

“All the best, “ I said, just about to close the door.

“One favour', said the girl.

“Yes?” I turned back.

“Can you say thank you, to….. to the family who gave me my new liver? Please?”

Her question struck me to the core, and again I felt the injustice of it all. But my façade of happiness had to continue. I had to act, for the sake of guarding her innocence. “I’ll try my best', I responded, in a falsely jovial voice, giving her a final wave.

Hastily, I made my way down the stairs and out into the pavilion because tears were streaming openly down my face. The setting sun beat down upon me, and once again I wondered how such a sweet child could be made to suffer so much pain and hardship. It made me want to scream in frustration, that I could do absolutely nothing to help her, physically or financially; that the mere exchange of words was all in the world I can offer at this stage.

I knew how she had this genetic disease of the liver: her parents were first cousins. Consanguinity, a common practice in Pakistan, puts any offspring at greatly increased risk of certain genetic diseases, because the parent’s genes are so similar to each others. A child inherits two copies of any given gene, one from each parent. With some genetic diseases (Autosomal recessive), the presence of just one faulty gene (inherited from one parent) does not matter, because the other copy of the gene (inherited from the other parent) is healthy. However, when the parents are first cousins, any faulty gene is more likely to be present in BOTH parents; making it much more probable for the child to inherit both copies of a faulty gene, and hence suffer clinical disease.

It was ignorance that made me angry. Ignorance on the part of the parents, or whoever decided that such a marriage was, in any way, a good idea. A haunting statistic floated to mind: in the European countries, 33% of all newborn babies with heart disease are of Pakistani origin. The association of consanguinity and cardiac, liver and renal defects is well known. If only people could be educated into a better way of thinking, then fewer children would be born with malfunctioning hearts, livers, kidneys etc. And certainly, this child would not have to live every one of her numbered days with a severely debilitating liver disease, which makes it so difficult for her to lead a normal life.

Chapter 4: Conclusions

In the end, I guess the emotional impact of witnessing the child’s background, her innocence and misfortune in theatre are hard to describe in words. I certainly matured a great deal during that short space of time; thanking God for the small blessings that we have in life. Fresh perspective from my parents helped me to feel better: at least this child lives in a country where liver transplantation is a real option, which is free of charge. Had she lived in Pakistan, such an operation may not have been available, or perhaps would have been too expensive. Whilst her situation is sad and indeed to be pitied, at least here in this country, she has a real chance at life. The factors leading up to her current condition are complex: it is not simply a two-dimensional “blame the parents” phenomenon. The concept of consanguinity is one that is deeply ingrained in that part of the world, and it will take many generations to eradicate this. From the notes, I gathered that her teachers at school were very supportive, even raising enough money to enable her mother to take time from work to spend with her. Reading about such compassionate acts makes even the most cynical of us soften and smile, as we realize that there are still good people in the world.

That is where this journey ends.


I have read this article, umpteen times but even today, my heart is heavy with different emotions - at the way the children suffer because of the fault of their parents, how some good samaritans help is available for the child and lastly, we are assured to have a good, compassionate doctor, in the family.


Renu said...

Certain things must be prohibited irrespective of caste and religion, like marriages between cousins and unlimited progeny.

Destination Infinity said...

That was a touching article. All the software engineers in India ought to read it at least twice. It should be hard to be a surgeon and we should thank such surgeon's and other doctors who take so much pressure to save lives. Unlike the software engineers. Thanks for bringing this to us.

Destination Infinity

Sandhya said...

Renu: Yes, Renu. Unlike other religions, Islam supports marriages between first cousins. Will education help them? No govt. rules can change them.

Destination Infinity: She dreams of becoming a surgeon. She is ready to face these tensions. Now, she is assisting in paediatric surgery. She is so happy to handle the newborn babies.

wordsndreamz said...

Wow!!! That was so touching and I was at the edge of my seat - till the end - not knowing whether the child will pull thru or not!

And you sure have very talented nieces!! She has got such a wonderful way of writing as well!! It was wonderful to read! ANd that little child's spirit!

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