Chapter 59-Sick Kids

August-Sep 1997

Having successfully laboured through an exhausting OG posting, complete with Labour Room part Deux, loads of history takings, abdominal palpations and foetal heart sounds, I find myself in the middle of a Ward Leaving which is a breeze. Gynaecology, the focus of this particular posting, is easy, even fun. The only tricky part is Dysfunctional Uterine Bleeding which has hormonal balance, prostaglandins and such things in it and because it is an Exam case, I make an extra effort to get my head around it. But I can't.
I'll just hope I don't get it for exams. The other cases are fine. Cancer Cervix and Endomterium. Uterine Prolapse. Fibroid. Ovarian masses. They are a bit like a surgical case and there is some logic to them.

Apart from the Labour Room stuff and cases, exams also consist of Instrument vivas, an Operative surgery section, X-Rays, surgical specimens and a general Viva. In OG, the major instruments are Doyen's retractors which are used extensively and I have used it in a C Section. Then there are the forceps.
Long and curved, I have seen babies being pulled out with these. The head is held between the forceps and good old fashioned pulling does the trick. Sometimes a vacuum pump is used where the baby is literally vacuumed out. I am told there will be a tray with all these (and many more) instruments kept for us. I'll cross that bridge when it comes.
Of course, no OG posting is complete without a complete knowledge of how a baby is actually born. In detail. There is a long pnemoic for it which goes starts with Engagement of the head and has components of Flexion, Extension, Internal Rotation, Restitution etc with baby descent occuring throughout. Theis descent bit is is the most important and a stuck head will warrant a vacuum or forceps or sometimes, a C Section.
When the baby is born the other way round, it becomes a breech. Here, sometimes a foot is the first thing to come out and then it becomes a Footling.
Sometimes the face comes out and then it's a Face Presentation.
On many occassions, where it is vital to just attend something, like a marriage or a party or anything, that appearance is also called a Face Presentation.
If the baby lies transversely and can't come down, it's all upto the OT guys to do their C Section magic.

Armed with all this knowledge and sailing through the Ward Leaving, 16 of us move on to our next posting-Paeds.

I dislike Paeds. At first sight. The Ward is on the 1st floor, right in front of the staircase and is Ward 21. It seems overcrowded at first, till it dawns on me that each kid is obviously accompanied by his/her mother. The Ward consists of small cot like beds with railings and is divided into 2 sections, the first 8 or so cots nearest to the door harbouring the sicker kids.
There are all kinds-Heart disease, TB, pneumonias and bronchitis, abdominal masses, sometimes malignant, febrile rashes and of course, the scourge of all babies-malnutrition and diarrhea.

Just outside the Ward is an examination bed with an overhead lamp where babies brought as Emergencies can be seen quickly. How anyone can examine a baby or a toddler is still a source of constant amazement to me. Everything is so small, delicate. And of course, the kid can give no reliable history.
In Paeds, starting an IV Line is an art and the Pediatricians are called from everywhere to start IV Lines. They are the kid specialists for this kind of thing, better than the Anaesthetists who would like to claim this skill all to themselves.

I can't take sick kids. Many of these will get better but some will not. I have been told that in the process of becoming and practicing as a doctor, one gets detached, sometimes immune to the suffering one has studied so hard to try to alleviate. I hope this does not happen to me, that patients-kids or adults, remain kids and adults and not turn into "Stroke" or "RHD, MS, MR" or "Leukemia" etc. I know it will happen and has already started to happen.
I cannot recall a single patient's name that I have examined. I do recall, however, what condition they had and what the findings were.

The Dept is headed by Chinu-a Senior Professor, immensely knowledgeable and who commands the respect of his entire team. His main penchant seems to be a massive emphasis on breast feeding and there are posters in the Ward reminding us about this. Dr VB is a small, cutish guy, also Senior and is a Neonatologist, a very suitable job description for him at first glance. Dr N is the Second in command, looks very scholarly and is very tall. The Dept is rounded off by DR AB and Dr M but most of our classes are taken by Senior Residents, one of whom is Somya, a lovely lady who takes great classes to boot.
I struggle through Paeds. The subject is similar to Medicine but I have to mug up all the Milestones-when babies smile, walk, turn, run, draw triangles and squares, say da-da and ma-ma and how they grow-head and arm measurements, weights, heights.

Paeds is memorable only for the times I scoot across the corridor to the Duty Doctors Room which has the biggest bathroom in the entire hospital. Closing the door behind me, I light a tar filled nicotine bomb, close my eyes and contemplate the purpose of my current existence for the few minutes. I don't do this often, for the Room is also used for classes and the smell can be pervasive but at times, I need to run out of a Ward full of sick kids and just be alone. One time, Chinu is taking a class when I emerge from a pale blue cloud of smoke and our eyes meet, but I dash out with not a word. Nothing came out of that thankfully.

Chapter 58-The Constant Labourer

May-June 1997

The days leading up to Labour Room Part two are slow and long drawn out. The excitement and anticipation that accompanied my first stint there is pretty diluted but after 14 days of the OG posting, I, along with the other 5 usual suspects, head past the Eclampsia Room and 4 or 5 heavily pregnant ladies, through the yellow double doors of Labour Room and into the action thriller that Labour Room often is with the unique all pervasive constant whiff of blood mixed with the unique smells of amniotic fluid and newborn baby, like a strange room freshener set to auto.

The Labour Room team is led by Dr Sethi, (someone I know through Shom and his gang) and also consists of three other residents who will man it from 8 to 5 every day for the next 3 months. At 5, the corresponding Duty Team which varies every day depending on the Unit on Duty will take over. Mondays-Thursdays are Units 1 to 4 and Fridays and Saturdays alternate between Units 1 and 3, and 2 and 4 respectively. Sundays are by rotation, but not for us of course.

Things start off as before with rapid allotment of beds to be monitored, deliveries to be conducted, Caesarians to assist and various forms to be filled. The space between the door and the delivery rooms is occupied by a yellow board stuck to the wall on which rests a massive register with details of every delivery and their outcomes, times of births, modes of deliveries etc. Next to this is a table with scattered bags, white coats, stethoscopes and books. A trolley with a green mattress lies next to this, at right angles and partially blocking the doors that lead directly into the OT. On the wall opposite to the heavy register is a wooden coat hanger which is perpetually occupied by green gowns, caps and masks.

In the delivery rooms, each occupied by 2 steel tables, a kind of a 2 step stool, a light fixed to the wall opposite and IV stands, lie the almost mothers. Stuck on the wall opposite each mother to be are their respective partograms. A couple of new born baby cots lie against the wall in the corridor which receive each baby for cleaning, tying the identifying wrist band and for paediatric examination if required.
There is general controlled panic as usual.

To an outsider, it seems like there are people, all dressed in green gowns, caps and masks with stethoscopes hanging from their necks, running about, shouting orders at 6 Final Years, who are moving around with controlled reluctance in varying degrees of exhaustion. That would be us. The second stint of this place is much more tiring than the first, because there is less to ogle at and fewer new things to learn. This time round, we are experienced and are supposed to just do things without much explanation. The pressures are greater, the expectations higher and the margins for ignorance and error significantly lower.

The SLR is conected to the CLR via the OT complex which consists of 2 Operating Rooms next to each other. The OT's are therefore connected to both Labour Rooms and are always occupied, especially after 2 PM when the routine cases are over and the long line of Caesarian Sections can take over. Often, in the morning, the routine OT list is interrupted by an Emergency Section and we, as Labour Room Final Years are expected to scrub and assist. This is both a chance to actually do some surgery and a hugely welcome break from the tedium of delivering babies and charting partograms.

One evening, well into the posting and resembling a walking zombie I am assaulted by the fumes of formalin in the SLR. It's stinging, pungent and very very strong.  It is unbearable and I grab my mask and get out of there into a room next to the SLR where the air is more normal. Dr S (not Sethi), who is the Senior Resident for the night is running back and forth from CLR to SLR trying to figure out what's happening. He is accompanied by Suzie, who we all imagine is his future wife to be and we are frantically shifting SLR patients outside. It's quite a task moving them on to wheelchairs and trollies, all getting cramped in the smallish  room just outside the SLR.

It seems that the CLR is getting fumigated, a process initiated by someone finding large colonies of Pseudomonas on the walls and in Savlon bottles and all of that formalin has made its way into the AC vents and into the shared AC system of the SLR. The CLR is vacant of course, all patients having been shifted to the SLR, but no one has bothered to realize that the bloody AC system is common.

I stand outside the SLR and take a few deep breaths, wear my mask, hold my breath and run inside. My eyes are watering and a very quick, deep breath later, I am helping to get a patient out of the bed and into another trolley to take outside this formalin hell. The others are doing the same. After a few minutes of very rapid activity, all patients are now outside a completely fumigated but totally uninhabitable Labour Room (s).
This of course does not absolve us of any monitoring or Syntocin drip administration or the like. Fortunately no one is in active labour right now but S walks over with his characteristic deliberate slow dignified walk and tells me to "keep my hand on the pulse" of a particular patient because she is at risk of a uterine rupture. If this happens, it's a catastrophe and a rapid rise in pulse rate will give us advance warning. This is frightening and I feel very responsible and scared at the same time. What if the pulse does rise and no one is around? Do I go around shouting for help?

I am stuck with this for the next 2 hours. Hand on pulse and I don't dare move from the stuffy non AC room where all the patients now find themselves. People go for dinner and come back but I stay there till I am told it's all clear.

A couple of days later and inching towards escape and freedom, I lie exhausted on one of the beds in the Duty Doctors room, opposite one of the Special Ward Rooms. They are numbered from 1 to 10 or so and the numbers are preceded by either A or B. The standing but rather stale joke is that Cancer patients are never admitted to Room B9.
3 of us lie there at 3 AM, bone tired and hoping the morning gets delayed somehow. But what does get delayed is our precious sleep. At 3 AM there is a loud knock. Naveen, who has made a hobby of assisting Caesarians, is frantic. Madam A is on her way to the OT to do an "Ectopic Pregnancy" case. And we ALL have to be there.

This has more implications than loss of sleep. Madam A will expect us to know about the case. The history, the findings, what the surgery will involve, and numerous questions will be peppered throughout this whole drama. Even if she does not physically come, she will make it a point to come around the next day and ask. In such situations, we all stand in a small circle in the CLR and hope against hope that the questions are not directed at us.

The procedure lasts for an hour and now I am too buzzed to sleep. So 2 of us head out to the shacks for tea and chat till the first hints of sunrise come on the horizon. I've never seen as many sunrises as I have in this posting and it's quite a new experience. The slow lightening of the sky, a change of colour from black to blackish-blue and finally to varying shades of orange and yellow. Birds start chirping, the air turns slightly chilly with the early morning breeze and a new line of patients, often from far away and having spent the night on the footpaths outside Jipmer,  make their way towards the front gate, assembling in a disjointed line for their turn. Some of them will turn into guinea pigs for people like us.

Inside the hospital, Nurses wander from room to room with their drug trolleys and a note-book on which they have to record what medicines have to be given to whom and at what time. The cleaning people start early. Around 7, the first wave of Junior Residents come in, all fresh and alert, shaved and dressed. They make a quick trip to their respective wards to see their patients before Rounds at 8. Various other sundry people, some in the brown uniforms of the "Group C and D", some in Nurses uniforms, and some "OT Brothers" move around.
The 5 of us on the other hand look unkempt, haggard and dirty. I smell of amniotic fluid and blood. It's a a weird feeling to walk around in the hospital at 8 AM looking like that. But this is a hospital and no one really cares. Zombies like me are everywhere, post call in all specialities, all of us shuffling off to our respective bikes parked outside like wounded comrades in arms.
It's a good time to share battle stories, who said what to whom, who screwed up and who got shouted at but eventually the talk veers around to Final Year and the impending Exams.

As Labour Room draws to a close, I find myself with mixed feelings to what should be a welcome end to a gruelling 2 weeks but, in reality, is the beginning of a 4 month hurdle race to the finish line. One of the few joys of Labour Room is that one is so involved in the whole posting that all else takes a back seat. All of Medicine, Surgery, Paeds, Ortho. We are exempted from all theory classes bar OG and even here, it's a common sight to see 6 Labour Room occupants struggling to keep awake or on the odd occasion, snoring lightly.

The 14 day posting becomes a kind of refuge from the terrors of Final Year that lurk just outside the double yellow doors of the CLR.

There is much I have learnt-Conducting deliveries, monitoring pregnancy, active management of a lady in labour, assisting C Sections etc. More importantly, I have learnt how to function on adrenaline and coffee, how to ignore screwings, how to be time efficient and how to prioritise work and the value of teamwork. I have learnt that people die, some before they are born alive. And I have watched extreme grief and extreme joy-both at arm's length.

Labour Room has also, quite insidiously, introduced the concept of team dynamics. Lock up 6 similar people in a space and circumstance for 14 days and things happen. Bickering, bitching, adjustments, covering up for goof ups-all of this has happened and will continue to happen to all subsequent batches. Someone will invariably be labelled as a "suck-up", someone will get labelled as a slacker, someone else will be a stubborn SOB unwilling to exchange duties or nights off. Intentions can be misinterpreted and the mental stress of being on full alert for 14 days, 18 hours a day is only mitigated by the fact it does not last forever. I am fortunate in finishing Labour Room early but a few will finish it just 24 hours before the Send -Ups. In some ways , perhaps, that is better since there really isn't much they can do about the exams.

I think about all of this while dealing with an aching back, sore muscles and a fried brain swimming with drug doses, partograms, IV lines, OT call slips and what happened to Muniammal in her expedited 2nd stage of labour. I think of all this at 230 AM when the world is asleep but the hospital is buzzing with activity, if you know where to look.

The phone rings (again). Casualty is on the line with yet another lady in labour. The Duty Resident, who managed to get away for a quick 30 minute nap is summoned and the two of us head off to Casualty to assess the lady in question. Satya is my Resident, walks with a slight hop and limp and we hop and lumber respectively to the controlled chaos that Casualty is. It is beginning to appear that the entire hospital is in a state of controlled chaos.

Casualty is somewhere near the front of the campus, close to the Main Gate. There are rumours of a new Casualty block somewhere but no such construction has started yet. It is much needed since this one is bursting at the seams, people everywhere-patients, trolleys, doctors, interns, patients' attenders. The sounds are as varied-machine bleeps, rushing footsteps, occasional wails and screams, Residents shouting at Interns, Interns shouting at patient attenders, attenders standing quietly by the side hoping for miracles. I have seen many a Burn case here, all with stories of "the kerosene lamp was kicked by the cat" and "my saree caught fire on the stove" kind of barely believable stories. Many a poisoning case, some accidental, some suicidal. The odd patient in coma waiting to be shifted to a perpetually occupied ICU, people with fractures being plastered and X-rayed. And some polytrauma patient no one wants to takes.

I have seen this scene a number of times but always with the mission to reach our patient-the lady in labour who lies waiting in the OG Room for us.

A quick history to establish gravida and parity, a PV examination to check position and descent and we are off. One more added to an always growing list of deliveries. It feels good to be here since I can start monitoring patients from the time they arrive to the time they leave after a successful delivery.I don't have a sense of completion with this particular patient since I will be off in a few hours. Nevertheless, when I am asked to do a PV, feel the head and check dilation, I feel more like a doctor than I have ever felt in any posting before.

The Labour Room is not very busy tonight and the routine after such a Casualty visit is, time permitting, to head off to the shacks for tea, biscuits and the odd nicotine fix. It's 4 in the morning, still dark and relatively quiet but the shacks are always busy. We walk out of the main gate, see the rows of patients and attenders sleeping on the footpaths and on the median of the highway and make our way to Casino where the "Master" is making the first tea of the day. This is always the best since the same tea leaves are probably used many times and the tea gets progressively worse as the day goes on. This is a good place for some gossip with fellow Interns, some in Medicine, some in Surgery and with some juniors, who, it seems have nothing better to do than drink tea after yet another party. My white coat and steth makes me look all senior and serious and the obvious sleep deprivation just heighten the mystique that surrounds a Labour Room occupant. The shacks is also a good vantage point from where to observe the Casualty. Any Ambulance/car/auto entering the main gate is tracked to see if it turns left to the Casualty and if so, we often dash to make a quick check.
"Is it our case"?

As an aside, a tea in the shacks is also referred to as a " Casual Tea".

The clock ticks on. Dawn breaks and the hospital comes to life.

We had a small leaving party in labour Room the previous evening, with Pepsi, cakes, samosas and the like, all sponsored of course by the Labour Room Senior Resident.
The five of us-me, Narayanan, Naveen, Pakha and Pajanivel-will head off into the world again, a world with Final Year Exams and the prospect of doom and gloom written all over. I know I have to read like never before and start praying, also like never before. There are 3 more postings to go-Paeds, Medicine and Surgery and that's it.
The end of my MBBS course is near.

Exams, reading, clinics, tests, vivas, screwings, royal screwings, notes, books, despair, loneliness-the life of a Final Year student.

Chapter 57-Post Summer Vacation Blues

May-June 1997

The Ramanathpuram misadventure was just a small welcome break in what has become a long drawn out struggle to stay afloat in my ocean of books, patients and classes. Final Year is unique in that constant study is not only needed, it is expected. And expected of every Final Year, by everyone else. If I am spotted in Snappy, I start to feel guilty I'm not in the Library or mugging in the room. Tea in the shacks has similar consequences. The guilty pangs have started-a feature of the Final Year student.
I can handle a barrage of "Start Reading" exhortations from the Consulatants but frankly, "Start Reading Bugger" and " Bugger, your prognosis is dismal", " This is basic stuff Bugger" and the like are beginning to grate on me.
Final Years are the whipping boys of everyone. The First Years torment us with Anatomy and Physiology, the Third Years with their newly acquired knowledge of Pharm, Micro and Path and Interns with their know-it-all attitude. The Interns especially, just a year senior and only 4 months out of their own Final Year hell, have forgotten the trauma, the trials and the tribulations they have suffered to get there. Sid makes it a point to walk into what has been a nice pleasant Snappy evening and hit me with Medicine case scenarios. Deb wil usually follow him but will keep wise, silent counsel. Bong used to be a master at this kind of mental torture but has thankfully graduated and gone home. Shom has too many worries trying to sort out the politics in his Department and Rahul is sensible enough to realize that most people just pass from sheer luck and keeps away from any academic conversation.

My last vacations in MBBS are over. The next 6 months will be my last in this course and all I can see is proverbial puddles of quicksand and minefields to somehow navigate and dodge. The next 4 postings will complete our course and then it will be Send-Ups and after a few days, the Finals. Supposedly the toughest Finals anywhere. I start with OG again, continuing with Paediatrics next and followed by Medicine and Surgery. Orthopaedics and Paediatrics are considered minor subjects and will constitute a part of the Surgery and Medicine papers respectively and therefore only have the one posting. Which I'm very grateful for. A full exam in Orthopaedics would have had me reeling in despair. For the next 4-5 weeks, though, I'm back in the Ground Floor corridors of OG.
This time, the emphasis is on the Gynae part of the subject and most of our Ward Clinics are held in Ward 16, opposite the SLR. Ward 12 houses the Obstetric related patients, some waiting for a Caesarian, some just post-Caesarian and a few others kept in observation for various reasons. This is perhaps the only ward where "Floor Admissions" are allowed and so, on occasion, I see a patient without a pre-assigned bed. This is rare though and I have been impressed with the efficiency of admissions and corresponding discharges in all the various wards and departments that keep Jipmer looking well organized and clean.

10 of us troop in to the Ward at 9 AM sharp and bid adieu to the first 6 in the batch. They are heading to their last Labour Room posting where I shall be banished to in 14 days time. I am also now reading in earnest. Back from class and a few teas later, I am in the room planning my assault on the exams. This, however, I find, is more of a feel good strategy than any concrete progress. I am very very good at planning reading and studies.
The planning is where I usually stop though. Over the last few months, I have made extensive detailed plans to study Medicine, Surgery and the like but I usually head off for tea/booze/food/gossip once this is over ad the whole plan then needs to be continually revised, the time allotted for each topic getting progressively shorter. This is a malady I have not been able to fix since I joined this blighted course.

I need to finish Shaw, the Gynae book and also go over Dutta for the last time, since with Paeds, Medicine and Surgery to follow, there won't be any time to get back to OG. Shaw is not big and I find Gynae quite easy. It starts off with the usual Anatomy chapters and moves on to core Gynae including cancers, endometriosis, PID and the like. It's the thinnest book in Final Year but will carry 40 out of the 80 marks in the OG paper. There will also be a Gynae case in exams and so this cannot be ignored.

The tension levels are rising. I can feel this and so can all my classmates. Condom and Anup are in the same batch and I meet them off and on in the corridors, all the talk centring on the latest cases they have seen and the weird findings they have missed. In the exam, any and every case is fair game and it seems that with every passing case discussion and in gossip sessions with the others, my huge lacunae in knowledge are getting increasingly exposed. The ease with which some of the others discuss the more complex cases leaves me despondent and unsure and back in the room, all attempts at reading are stalled by despondent thoughts on gross under-preparation and helplessness.My books are strewn all over the place-on the floor, on the bed, in the black bookcase Vikrant once owned and scattered all over my table. It takes a lot of effort to blank all this out and just read Gynae, the subject I am currently posted in. 
A lot of Final Year outcomes depend on what happens inside your head. It's a Test Match in cricket terms, a lot of dips and the occasional high. There is only one acceptable outcome. I have to pass. Maybe.

My room, 428, is on the Top Floor in Osler House. The Osler Annexe is a shorter, equally tall building at right angles and my windows face the squarish space enclosed by these two hostel buildings. I have a double room all to myself and next to me is an Intern, who is intensely private and his door is mostly locked. I would do that too, except that I can't find my keys in the mess that my room is in and I have had to resort to unscrewing the latch. When I leave the room, all I can do is close the latch which results in the doors being partially pushed open, the mess inside visible in all it's glory. I think this is the reason I have not been burgled yet.
The windows, however, are open to the outside and face some tallish trees. When coming back from my short summer vacation, I brought a couple of cans of Baked Beans, which I love, and which my mother had insisted I take back. This can be heated on a stove (which I can borrow from Anup) and gobbled up in the dark times when I am hungry and there is no time to go out hunting for food. (Most of Final Year is like this).
One day, back for lunch, and looking forward to a quick nap, I peep into the small gap left by the partially open doors and see my can of Baked Beans lying neatly on the table next to the window where I had for some reason, left it.
I also see this:
There is a monkey. The monkey is small, brown and sitting on his haunches next to my Baked Beans can. I stare at this scene for a second and the monkey discovers me, turns his head at right angles and stares right back. The next minute, both monkey and Baked Bean can have disappeared through the window.
At this point, deep into Final Year, nothing can faze me.

My neighbours on Osler Top (or OT) are my usual companions on my long, ardous journey.

Bhargav, an Intern, is rather short and stocky. He occupies a single room in the middle and is often seen smoking yet another cigarette with one leg swung over the 4th floor parapet. He wears round glasses and when I see him, all he says is "Hey Golu, reading going on OK"? (क्या बे गोलू , पढाई ठीक है?)
Anup is in 413 and he is always found on his mattress underlining some book and making notes of what he reads. I don't know what he actually reads since all his time is spent underlining and making notes of ALL that he reads. I tried to do that once but found that everything went straight from the book to the notes, bypassing me completely.
Condom is happy in 427, having ditched his roommate, Harry (Harpreet) who now lives in 415. Harry is the lone Sardar in campus and is pretty studious, doesn't (yet) drink, but loves to stake out the eating joints. He has discovered a video game called "Brick" where patterns of bricks fall and one has to arrange them so that none accumulate. A bit like Tetris I suppose.
Lobsang, a super senior is in 426, just 3 doors down and separated from me by the loos. He has been an Intern for a while, keeps mainly to himself but is otherwise nice to talk to.
Vinod is my other classmate in this wing. We call him Dodo for unknown reasons and he likes to write poetry. Maybe Final Year does that to you. His poems unfortunately go way over my head and actually make me laugh, though since he is dead serious about them, I think that would be rude. He has met the girl of his dreams, another classmate of mine and many times, all I see of him is when he's running down the stairs to Curie House, presumably late again for an appointment.

After a few days of this new, final semester, at 1 AM and after a rare episode of intense reading, I take a bathroom break. I am still there when someone strolls in. It's a girl! She strolls past into a stall, says "Hi" and goes in. Anup is there too, and in stunned silence, we go out and wait for her to walk past us into my neighbour's room where the door is promptly shut. Anup and I tiptoe to 429 and very quietly, put our ears against the door. Only some soft music wafts out. That's a tad disappointing but it still serves as some entertainment for heavily entertainment deprived Final Years.
This happened to VSP, another Intern also. Same situation and the girl in question waltzed into the loo, took one look at him, said a husky "Hi VSP" and went into the stall. VSP was left stunned for a few minutes.

Back to Clinics and the days pass by quickly enough. Fortunately, in the exam, I discover we won't have to do an actual Per Vaginal exam to get the findings. So, for example, in Cancer Cervix, we'll still have to take a detailed history and do the rest of the examination, but the PV findings will be given to us. That greatly simplifies things. The history focuses mainly on vaginal bleeding and discharge and swellings in the abdomen and is manageable. Every passing day of Clinics, the occassional test and the evening despair brings me closer to Labour Room. This time, some of the excitement is missing.

But it's still 14 days of 24/7 action. I might even miss it when it's over.

Chapter 56-The Ghosts and the Darkness

Mar-April 1997

Ramanathpuram is about 25 minutes away. It's a typical small village with green fields, thatched huts, hard working farmers, stray dogs and clean air. It's not far from Pondicherry at all but all around this place, there are hardly any lights and nearly no traffic at all, and just 20 minutes from civilization, it can seem like half a world away.  The village also has the Rural Health Centre (RHC) run by the Community Medicine Department in Jipmer and where Interns like Rahul are posted for 6 weeks at a stretch. 

According to hearsay, a lot of these 6 weeks are spent in rural bliss with long walks, cricket in the evenings, toddy in the mornings and budding romances.

Ramanathpuram, or more specifically, the RHC, is also apparently occupied by ghosts. This reputation is quite old and has been "substantiated" by numerous independent reports of "seeing something in the night", "locked doors found unlocked", "doors banging in the night", "strange sounds", "a light breeze when there is no wind" etc. I am quite sceptical frankly, but the belief runs strong and I hear that the Community Med Department had even organized a prayer to rid the RHC of these ghosts. The villagers are also in the know apparently and are well aware of our haunted RHC.

Around 11 PM one cool evening, Plaha, Vinay and I get our respective bikes- 2 Yamahas and a Suzuki -and start off. Ram, a batch junior and with nothing to do either, joins us. It's a nice evening, typical of a seaside town with a lovely breeze to keep things cool. We exit from the main gate, turn left and go down till the Muruga crossing 2 km down. Straight from here will take us to Raja theatre and eventually the beach, but we turn Right, past the Arcot Biryani and the adjacent mosque.This road, which is beginning to see some development, has some factories on either side and very soon we can smell soap coming from the Hindustan Lever factory. A short distance away is the Hush Puppies factory where shoes were on sale for Rs 700 last year. I know Chetan bought about 5 pairs there but I was too lazy to even go.

This road is not well lit and has a few holes here and there. Traffic is light and we weave in and out avoiding the holes, and, after a traffic check post, are soon on a clear road under a brilliant starlit sky. Wide open spaces on either side, no traffic at all, no lights and apart from our bike engines, no sound. We are only 10 minutes from the College Campus. The road is fine and we trundle along in silence. It's quite cool, chilly even and the conversation drifts from general College chatter to the awesome night sky and finally, naturally, to Ramanathpuram and it's haunted history.

It's just aimless, nightime biking on less well travelled roads, a favourite past time. Right now, a small, roadside shack with a "Master" making tea/coffee and some puffs or biscuits would have been perfect but there's just empty fields for miles. A few minutes later, we spot the faint outline of a church like building on the Right. It's in the middle of some fields and has a Red Light glowing on the top. I've never noticed it before and the combination of the haunted gossip, the chilly air and the slightly misted over church with the Red Light makes everything a bit spooky. There is no other artificial light anywhere and when we turn off the engines, that light is the only thing we see.

There is utter silence. Plaha wants to take a detour and go into the fields to explore this "church" or whatever ruin like thing it is. Vinay and I are a bit spooked, though we cite time as an excuse and Ram will go along with whatever is decided. We linger on for a bit and decide that if Plaha wants to see if it's haunted, then he's welcome to do that alone. Which, he decides, is not much fun and we carry on, feeling slightly more chilly than normal.

Soon, the road dips a bit and I find Ousteri Lake starting on the Right. A small bus stop on the Left and some tied up buffaloes mark the gradual winding Right turn the road now takes.
Ousteri is a big water feature and has some villages scattered around it. Ramanathpuram is not far away and I can see some lights far in the distance on the other side of the lake, probably coming from the Pondicherry-Tindivanam Road.

Ram is sitting behind me and starts a theory about how ghosts can take the form of fires and follow you around. He seems very serious about it, but with Ram, one can never say if he's serious or bullshitting. About 5 seconds after this, and with the expanse of Ousteri on the Right, trees and fields on the Left and darkness all around,  we see a big fire on the side of the road.

I have to admit, this is very spooky. With muffled whispers (lest the ghosts should hear) of "Bugger!", we quickly carry on, with Vinay glancing back every few seconds just to make sure no ghost is riding pillion. The road winds around the edge of Ousteri, and a huge banyan tree and 5 minutes later, we're glad to see the Pathukannu bridge which will lead us to Ramanathpuram. We take a small breather here and being spooked ourselves, we see no reason why we should not share the spookiness and decide that Rahul, blissfully unaware of our trip and sleeping in peace, cannot be spared.

We make a short right and go across the Pathukannu bridge which leads onto a small road from where an even smaller side road to the Right will lead directly to the village. If we were to skip the bridge and keep on this Ousteri road, we would have been on a 2 Km stretch of empty, dark road leading to the village of Villianur. Eventually, we would have got back to Jipmer. Here, as they say, all roads lead to Jipmer.

But we're across the Pathukannu bridge and on a small dark road with a small canal on the Right and fields on both sides. There is a lone hut with a bare naked yellow bulb in the distance and this marks our Right turn into Ramanathpuram village proper. We bike across the small bridge and are immediately met with the smells of fresh cow dung and fresh green grass. The village is alseep and there is just a dim street light marking the short Left turn and a couple of twists and turns which take us outside the Main Gate.This is a walled compound and the gate is locked. Inside are some Interns, a Chief Medical Officer, a cook and some sundry other people. And maybe some ghosts.

By this time, thouroughly spooked and feeling a bit sheepish, our original "Meet Rahul and have tea" plan has changed to "Let's scare the bejesus out of him". Just beyond the main gate, to the left, is the Main Hospital/OPD complex. This is a smallish structure with some rooms for OPD, a Minor OT, a Delivery Room, some rooms for Health Workers and a place for a fridge with vaccines etc. Directly opposite the main gate, on the other side of an open space, are some more rooms for the cook and his flunkie. A small path leads from the main gate, turning left and leading to the Intern and Medical Officer Quarters. This path runs between the OPD Block and the Cook House and at this time of night is deserted.

We shut off the engines and quietly park the bikes outside the OPD, out of sight from the Intern Quarters where an unsuspecting Rahul is fast asleep. Or so we hope. Silence is maintained as we walk down the path, stopping to pick up some small gravel and stones by the side. The roof of the Dorm is asbestos and can get really hot in the day. But at night, when there is complete silence, small stones bouncing around can be pretty noisy also. No lights are on and it's all quiet. We stop right outside the Dorm boundary, marked with some wire and punctuated with a small gate leading upto the Dorm, and flick a small stone onto the roof. Nothing happens. Some more stones, at intervals and not too many. A gap of about 5-6 seconds between stones is deemed appropriate.
There is no sound for the first few minutes. And then...a small, slightly shaky voice...

"Abe, Rahul, get up. There is something there". This is Moharana, Rahul's co-intern and on Call for the night. The fact that he says Something as opposed to Someone is encouraging and we continue flicking some stones, making sure to suppress any unwanted giggles.
A few seconds pass. A couple more stones and the voice is slightly more urgent.
"Oye, Rahul. Get up Man. There is something outside..."

Rahul is very well built and is over 6 feet so one would imagine that not much would faze him. After a few more stones, well spaced, there is a groan and he says
"Go to sleep, Moharana, it's nothing".
But the noise continues and after 2 minutes Rahul is wide awake too.
"Yeah, man, there is something there". His normal strong dismissive voice has taken on an uncertain tone.
The lights are still off. Moharana offers to turn them on but Rahul says No. We all sit in silent suspense for a while. 
Moharana: "Oye Rahul, can you go outside and check it out please?"
Rahul: "No bugger. Just sit here."

They sit in silence and we can hear some suppressed murmurs. Now Rahul offers to turn the light on but Moharana declines. There is no one else in this campus and with it's history, Ramanathpuram has become very spooky and our plan seems to be working. The pebbles continue, spaced at just the right intervals. Just one "Thunk" on the asbestos, followed by 10 seconds of silence and then another. More murmurs from inside, separated by long periods of suspenseful silence.
This goes on for about 15 minutes and is danger of being an endless stalemate, so we decide to make some ghastly ghoulish noises to accompany the stones. Just for variety. A short howl. A small yelp. More stones.

The murmurs are louder. "Rahul, I'm scared."
"Shut up bugger. I'm scared too".

After 15 more minutes of this, something has to give and the lights come on. We can now see the two of them, sitting on their beds, staring outside to see what or who is there. We take cover behind some bushes and continue the sounds.
This can't continue indefinitely however. Ghosts don't win in real life and finally there is some activity and noise. Still hidden out of sight, we see Rahul and Moharana, clutching hockey sticks and cricket bats, walking very carefully towards the main OPD block. Our bikes are parked. Rahul hates to be woke up at any time of the day and especially, I would imagine, here in the middle of the night. He is also spooked and that is not good news for our very identifiable bikes.
The weapons are omninous and we run out in surrender before major trauma is inflicted on our beloved bikes.


There is no question Rahul is spooked. He is not on call and was giving Moharana some company, but he now wants to immediately come back to campus with us. Moharana is less than thrilled at being left alone to fend off the ghosts but has no choice. It is compulsory for Interns on call to stay on campus and sudden emergencies like bullock-cart deliveries can arrive with no warning. So he really has no choice.
We are quite happy that Rahul wants to come back with us. It gives us a sense of "Mission Accomplished" and having spooked the 6 foot Rahul, we head back on the same route where the fire is still burning and the road looks as ghostly and beautiful. The ride back is faster and Vinay needs to still check back over his shoulder to keep flying ghosts at bay
20 minutes later, we arrive at Johny's shack where even at 2 AM, a hot cup of tea and some biscuits wait. The constant rattling of the "Muttha Paratha" guy is reassuringly familiar, the terribly burnt tea tastes of a sweet successful mission and the potential tragedy of Final Year is relegated to the distant background, to be tackled inside the Campus gates, not at the shacks where one escapes from the drudgery lurking right round the corner.

The Surgery posting is still on though. My Ward Leaving comes and goes and I pass-not great and not a disaster.
What is a disaster is that half my Final Year is over and in about 5 months, I will face the toughest set of exams that perhaps exist anywhere.


As we sip our burnt teas and eat the Mutta Parathas, dawn breaks, slowly turning the black, partially lit night sky into a more uniform yellow and orange glow. The next five months are like the night and it will be up to me to end it.

I feel self-empowered and disembowelled at the same time. Impending doom overwhelms me.
The 2 week Summer Vacations could not have been timed better.

I start my 2nd lot of postings after my Summer Vacation. And it's back to Labour Room after that, the first pit stop on the home stretch. 

Chapter 55-Stuck gears

March-April  1997

Life is not all work and no play, although at times that is what it should be. Some of my seniors developed the routine of studying 5 hours daily after class Monday to Friday and relax on Saturday. This is not a routine I'm going to ever develop but the pace is increasing. So are the tension levels.
Normally a specialist in night-outs and last second cramming, I am getting into the habit of daily reading though this still has to reach the levels my more accomplished classmates have been at for some time now. If it were just a matter of mugging up a book and facts, that could have been easy. But of course it's not.

There are 3 distinct separate areas to study-Clinical Examination methods (with which I should have become thorough by now, but am not), Clinical Cases themselves and the theory. The Clinical cases deal with a lot of stuff that won't be asked in a typical theory paper but constitute the more important, or sometimes the more exotic types of diseases and their associated findings. The theory paper usually has things one can't really assess in a Clinical setting like long questions on Acute Upper GI Bleed or Management of a Cardiac Arrest, Management of Antepartum Bleeding etc.
Most of the time, since there is little overlap between the core theory and the Clinical topics and since one can fail the exam in either component, I'm having a hard time juggling between studying boring topics like Hypertension and more exciting stuff like "Approach to a patient with Chest Pain", or "Approach to a Patient with Splenomegaly" etc.
The traditional approach to exams, one that has been honed to fine art by many batches of Jipmerites is to read all the case related books and notes and leave the core theory for later. Who am I to go against the grain?

Many of these Clinical Case notes and "Approaches" are in the form of notes passed down to us from seniors and although they are undoubdtedly excellent, I have one major problem with them.
Which is thus.
In an exam, faced with a patient about whom one knows nothing, how will an "Approach to a patient with Splenomegaly possibly help me. How, in Heaven's name, will I know this patient has Splenomegaly or whatever (and thus have the correct approach) before I examine him with that particular approach. It's a Catch 22 situation and I get very depressed thinking about it. I'm sure I'm missing something important but I suppose I'll figure it out sometime in the next few months. One set of circulating notes has been written by Vinci, 4 years senior and it helps that he's written them in excellent writing-big letters, lovely cursive, good material. There are also some notes written by Amouchou, 3 years senior, and soon all I am doing is building a great collection of beautifully written, still unread, heavily xeroxed notes.
There are also other things besides notes and books. For Guillan Barre Syndrome, which will come as a case, there is an article in the New England Journal of Medicine which everyone reads. So I make copies of this too.

I'm trying hard to read PJ Mehta, a Medicine Clinical Exam book which basically lists out causes for everything. 10 causes each for the 5 differnt types of pulses, 20 causes of breathlessness etc. The various causes of raised jugular venous pressures and so on. It's a good book to read while in the Medicine posting but it's very painful to read. Shom tells me that it gets better as one's Medicine knowledge improves, so I suppose I'll take his word for it.
There is Golwalla, which I have no intention of reading. Just the name puts me off. I wish I had time to read the whole of Harrison's which has to be the most comprehensive Medicine book I have ever seen. Davidson, our core text book is dry as hell but I am assured that every time one reads it, new information is uncovered. I don't know. I haven't even read half if it.
Sid, a year senior and crazy about going to the US, recommends a book called Lionel HOP which apparently describes cardiac drugs very well. After a while, I finally see it with someone and discover it is actually Lionel H. Opie. I don't read it.
Some topics are better covered in Paediatric texts. The description of heart murmurs in OP Ghai, a Paed text is excellent. The rest of Paeds is a big blur.

Das, the Surgery equivalent of PJ Mehta, is considerably better and is vital to know. It describes the clinical methods for examining all the cases in Surgery from lumps to ulcers to breast masses and thyroid swellings. Masses in the abdomen and how to distinguish kidney swellings from splenic enlargements, the difference between transmitted and expansile pulsations, varicose veins....everything.
There are also 17 types of ulcers for starters and The 15 points to know when looking at a swelling,(The pnemonic is SSSSSCFTRIPPP, and of course, hernias and hydroceles.
Hernias are a problem. They are considered among the ABC's of Surgery, and in an exam, even the slightest of fumbles can signal impending doom. I hate hernias, especially when one has to undress a patient and get him to cough and watch his hernia become bigger. I can tell they don't really love it either, and who would, with 15 eager students looking on. It's worse if it is combined with a hydrocele, but such is the lot of the poor Govt Hospital patient. On the other hand, we have a ton of cases to see and I could not ask for more variety.

After the incompetence of Ortho and the vastness of Medicine, Surgery comes as a welcome, logical relief. I like this subject. It has definite examination methods, is logical and one can see things like swellings and ulcers. Medicine is all inside and requires some imagination.
Surgery, however, also is a strict Department populated by personality laden characters. The Head, Prof AK, is a super stylish man and has a great surgical and academic reputation. He teaches like no one else. He walks with a slight sway which also oozes style and wears horn rimmed glasses that seem to suit him perfectly.
He is also known to be lenient with attendance shortages. I hope he hasn't changed.
He is called "Chief". He doesn't have a nickname. A sign of respect I suppose.

Another Consultant is nicknamed supposedly after his dog, Benjy although I have never seen the dog. Unit 3 is the most colourful with 2 consultants we are all terrified of. Dr J and Dr P's classes are full of witty sarcasm and I am always a bit scared going into them. Dr P is also known as Uncle.
Unit 2 has one of the nicest Consultants I know. Always smiling and known to be a gifted surgeon, people queue up to go see him operate. He, however, is also of the "fair in exams" variety and I hope that he does not come for our exams.

Some of our Ward classes are taken by Senior Residents, people who have finished the Masters degree but have to spend 3 years working as SR's before becoming eligible for a Consultant position. Sonal, the senior in whose room I spent that fateful Hasmukh Lal night comes on occasions. He takes excellent classes. He takes a class on Gastric Outlet Obstruction and I quiz him for a few minutes after on the types of gastric drainage procedures. This is probably not really necessary at our level but he gamely explains the whole thing.
Dr K, the 2nd Consultant after Chief in Unit 1, and to whom I lost a Badminton match once (mainly because I ran out of breath), is earnest and mild and can take a great class. He is sometimes hampered by not knowing when to stop teaching us poor MBBS students, so one of his Breast Cancer classes goes like this:
"You can do this also, or that also for this stage. 1 +1 may not be 2, sometimes it is 3 and sometimes it is 4". And ends with a "Is it not"?
At our level, I need to know what to do for each stage of a Cancer Breast. Knowing many options is not really helpful. And it is a hugely important case.

Our Surgery textbook is called "A Short Practice of Surgery" and is written by Messrs. Bailey and Love. I would love to see who came up with this name since there seems to be nothing short about this 1200 page double columned monster. It's not as bad as say Harrison's, which is in 2 volumes and needs a microscope to read properly but then Harrisons is not essential reading. This is.
However, like any good British book, it's easy to read and the edition that my seniors have is widely considered the most readable and well written. The current edition has been expanded and the book has become wider and according to some, Bailey has "lost its charm". When medical tomes become "charming", you know you're doomed. The Ortho section of Bailey is supposed to be well written but that time has passed for me. I should have read an Ortho book called Maheshwari then but I was too petrified of Ortho and exams were too far away for me to bother. Most of Surgery is occupied by the Gastro-Intestinal system and it's millions of diseases. Then there is Urology, whose lectures will start soon; Neurosurgery, whose lectures may be in the past without me knowing; Breast;Thyroid etc etc.

In the meantime, quite apart from clinics, our lectures are continuing at full speed and I am making desparate attempts to attend them. The attendance for all Final Year subjects-Medicine, Surgery and OG is counted only at the end of Final Year and so for 2 years, one is usually very blase about the whole thing. It's only in Final Year that nirvana happens and one realizes that unless one starts attending class "sharp sharp", one will "get screwed" or "happiness will get taken/raped".
However, in the ultimate analysis it's the clinics that will decide pass/fail and so most attention is paid to the 9AM-1 PM clinical sessions. I'm a bit scared of presenting a case, perhaps because of language issues and I manage to get through most of the posting with 1 short case and 1 long case presentation. The Ward Leaving will come and go. Fate has taken over and I just hope I've done some good karma in the past. There is not much karma happening now.

The evenings, however, provide some respite. Rahul, who is now an Intern, has been posted to our Rural Health Centre, 25 km away in a village, and he is rarely seen. I spend my evenings mostly with my comrade in arms-Vinay, and sometimes Plaha and Shom join in. Plaha is reading hard for the Jipmer Entrance Exam and Shom pops in now and then, usually on the way back from the hospital. He is married after all, so his time is not really his anymore.
Many evenings are spent in Snappy getting bored. There really shouldn't be any time for boredom but some habits, like endless tea and mindless gossip are hard to break. We miss Rahul and his company and curse his Ramanathpuram posting, a 6 week rural adventure which by all accounts everyone loves.

Plaha is getting bored too. He, along with Reddy and a few other guys from his class used to go upto Auroville in the middle of the night on their bikes and ride around, sometimes with all bike lights off. This can be a magical thing to do- with no external lighting at all the sky really lights up. They used to do this often till one of the residents there got up and let a bunch of dogs loose on them.
I have hardly gone to Auroville even in the day and a night trip with loose dogs running after us does not appeal to me. Ramanathpuram, though, does. I have been here 2 or 3 times before on class trips with the PSM Department. We had a small tour of the Heath Centre, were briefed on the workings of a typical Rural outpost and back we came. Plaha wants me and Vinay to come with him on a joyride there and we're quite happy to oblige. It's 1130 at night, we have nothing better to do and I love riding my bike anyway. The weather is cool, no rain and it will be a pleasant 20 minute ride. We can meet Rahul, have some tea in a roadside shack, gossip and generally end another fruitless day.

Ramanathpuram, here we come.

Chapter 54-Medicine Blues

March 1997

Time marches on. Even though exams are a few months away, the nature of these exams is such that I spend a few minutes every week telling my parents how easy and almost acceptable it is to fail in Final Year. I am working on the concept that anything, if repeated enough times, becomes the gospel truth. I certainly believe it, and I am working hard on my parents too. They seem to be continuous denial, as all good parents will be. "People fail, but surely not YOU?". Sigh. The pressure of expectation.
This has been reinforced by my Orthopedic experiences and I am just grateful that Ortho is not a full fledged subject by itself.

We have, past Ortho misadventures notwithstanding, moved smoothly into our Medicine posting. This is quite a biggie and for me is the most challenging. The first problem is the history. It's all in Tamil and nowhere is the patient's history more important than in Medicine. There are basically 4 systems which we will get as our "cases". CVS (Cardiovascular) means picking up heart murmurs, taking detailed histories of chest pain, breathlessness, cough, things called PND and NYHA grading and trying to figure out what's going wrong. The usual patient has multiple heart valve problems so a quick stethoscope to the chest can only pick up an orchestra of clicks, whooshes and shhhh kind of sounds, of varying intensity and pitch. These also have to be timed with the actual stage the heart is beating in (systole or diastole) and then try to see if the patient has Atrial fibrillation (Irregularly irregular pulse, much like my irregularly irregular attendance) or if the heart is failing....and if it is Right or Left heart.
Most of the time, there are atleast 3 such sounds happening simultaneously. And if they are faint or inaudible, one can do various things like get the patient to hop in place or lean forward etc to get them to become worse and therefore louder.
One time last year, while examining a case of Mitral Stenosis, someone tapped too hard on the chest and the patient soon had a stroke. Presumably, this was due to something getting dislodged and travelling to the brain.

The RS (Respiratory System) is worse. The symptoms are similar to the CVS but the examination is more subtle. The chest shape needs to be noted, breath sounds need to be categorized as tubular, rhonchi, hollow etc and they all sound the same to me. One has to tap the chest and hear for hollow sounds or dull sounds or whatever the underlying lung sounds like.
It's done by tapping a finger with another and there is a technique to it. My fingers are congenitally bent-like a Swan Neck Deformity, and I don't know if that's the cause for my not-so-good percussion. There may be a cavity in the lungs or perhaps some fluid in the pleura, or just to screw you in exams, everything can be there in the same patient. TB is an obviously common diagnosis but as I'm learning fast, the diagnosis doesn't really matter. What matters is how well one can pick up all the signs, how well one can take a relevant history and how well one can gel all these things into something that sounds sensible.
RS is a nightmare. If I get this in the exam, I'm done.

Next is the CNS and this is where things can go haywire very fast. I am told that examination of the nervous system is like maths in that the findings are objective, always mean something and if properly done, will always lead you to the problem. I have never been great at Maths and I am only slightly better at this.
The whole examination takes ages. Start with assessing Higher functions like speech and memory, move on to examining the senses and sensations in the limbs, chest, abdomen (fine touch, coarse touch, temperature, vibration), quickly jump to assessing all the muscles and their movements and tones, ending with the cranial nerves.
This may sound simple but it all has to be done in about 30 minutes and things can get interesting when one gets a stroke patient. Sometimes, they have lost speech and cant say anything. So there is no history to take. This scenario happens fairly frequently in exams and has varying consequences. For some, it's a boon because the examination technique and findings decides everything. For others, it's a nightmare because in an already high stress exam, it's not easy performing this examination on someone who cannot say anything.
Strokes are common, all varieties, and then there are spinal cord problems where finding the level of the problem is the key. Again, the diagnosis can be very exotic, ranging from Radiation Myelitis to Leukemic Metastases to Neuropathies but it's the findings that will make or break you.

The Abdomen is where I feel most comfortable. Tapping the abdomen to look for fluid is easy but can get tricky in really fat people. (Yes, I know the irony).It's all about finding enlarged livers and spleens and masses and not so tough.

And of course, we have no idea of what system we're going to get. AND, of course, multi system problems can happen quite easily.
Just to spice it up a notch.
But.....in the exam, we will have 45 minutes to take a history, do the examination (of ALL 4 systems) AND write all of it down in detail on a case sheet which we will not be allowed to look at when presenting the case. And there can be no discrepancy between what we say and what's on the paper.
And that is what kills many people.

I'm having a hard time. I present a case to Madam AA, who is very elegant but very expressionless. I'm just not sure if what I'm saying is correct or not and her blank face is very unnerving. Dr TD is the same. It seems that in exams, he will allow you to ramble on, digging your own grave.
Dr RP's classes are conducted half in Tamil, most of the talking directed to the local Day Scholars and it's easy to lose focus and interest. He's unique and his classes can get unintentionally hilarious.
Once, reacting to a weird diagnosis made by one us, he shouts
"Doctor! Get aback"...
He adds 2 symptoms to make a diagnosis (Spleen + Amputated Limb=Polycythemia) etc and I find his classes a bit tiring.

Dr KR is a genius clinician. His classes are fantastic and the best place to learn Medicine. He appears serious, with thick glasses and has written a book on Examination technique. He, however, also has a reputation for being very "fair" in exams, which basically translates to passing if you are up to it, or just watching the sinking ship sink.
Dr AD, on the other hand, is a "gem." He is the Head, always wears a tie, mostly red in colour and is held in awe by the rest of the Dept, mostly because he is the Head. He talks fast, in a slight Bengali accent which makes all the S sounds sound like Shh..He is very encouraging ad when he asks a question, always follows it with "Yesshhh, yessshhhh, tell me, tell me...I know you know, come on yeshhh yeshhh".
However, often one does NOT know the answer and the sheer terror of being blatantly ignorant in front of the Head and a definite Final Year Examiner is a sight to behold.

The schedule is much the same. Clinics from 9 to 1, sometimes 130 and I dread my turns to present cases. I need to get over this though, and fast. We often pass the Juniors, still in the First Clinical Year, taking their first steps in Clinical Medicine and I'm glad that even though life has become much tougher, the finish line is closer.
It's a tiring posting, very intensive and also exhaustive. The subject has no end and any case discussion can end up going in any direction. One wrong finding can lead one completely off kilter and sometimes results in a fail. It is the toughest exam to pass.

The books are pretty think and the variety confuses me. Some guys like to read Harrisons, the bible of Medicine, or atleast make it a point to bring it out when people are watching. Some read Kumar and Clark or Davidson and I am particularly pissed off when people say
"But such-and such thing is better given in this book, and some of the causes are better explained in that book, or the treatment is better in this but everything else is better there..."
I can hardly read one book and at first, I am infuriated but later, I just ignore it.

Medicine is a race against time. There is simply too much to read and absorb.
The Ward leaving comes and goes I fail. Not by much, but still.

3 postings down, 5 to go.

Chapter 53-The Not-so lovely-bones

Feb 1997

My first Ward leaving of Final Year is over and I am entering Orthopaedics now. We have had one or two postings before this one, nearly a year ago, and I am completely clueless about the subject.
Ortho, it seems, is a one man show. Dr P, who is the Head, is the all and sundry of the Dept, assisted by some Residents, Junior and Senior, one of whom is Manoj, now a Final Year PG about to go for his exams. He still sports that scowl as a normal default expression and I haven't really spoke to him after Vinay and I woke him up at 4 AM last year with our "Wakey wakey" shouts on the microphone. I have generally tried to steer clear from him except for the odd time when he arrives in Snappy on his Red Yamaha and since I am nearly always there, sipping endless teas and wasting endless minutes, we have said "Hi" a few times.
Hopefully, with his exams round the corner, he'll be busy enough for me to not to face that scowl in the OPD.

The posting schedule is more or less the same as anywhere, except that all case taking is done only in the OPD.  Just a few days in and I am still at sea as to what to do. The history one has to take is very different from the usual stuff one asks in Medicine/Surgery and it usually starts with some sort of trauma the unfortunate patient suffered. So, questions along the line of "Angle of impact, Direction of force,Movement limitations" etc become the norm and I can't get myself oriented to this at all.
I'm not getting comfortable with the examination techniques either. I need to measure limb lengths with a tape, check for movements of all the joints, feel the bones and see if they feel normal etc, and it's getting frustrating. I'm not very good at this and as the days pass by, I am getting increasingly worried about being completely incompetent in this Ward leaving.
We have constantly been told that for us, the emphasis is on a good history and examination technique. The diagnosis and treatment parts are not that important and will not really decide pass/fail in the exams.

The teaching is good, but my brain freezes somehow when faced with all misshapen arms, legs and joints. But there's plenty of variety. Fractures, some united, some not, some united in weird ways. Arthritis, resulting in stubby fingers that look suspiciously like my own. Bone infections that leave discharging bone bits coming out through the skin.
All these cases can and will come for our exams, but thankfully it's only one short case as part of the Surgery exam. Still 35 marks out of 150 is not something I can afford to skip.

So I'm drifting. Many of my batchmates are using this relatively light posting to catch up on Medicine and Surgery but I'm just spending time worrying how I'm going to get through this.

Rahul, however, has a plan. He has managed to pass his Final Year exams and is now in the starting phase of fairly busy Internship. He and I in fact, met in Labour Room last month where he was the Duty Intern when I was getting hammered with 24/7 deliveries and general paranoia, and I got to see first hand how cool life as a Labour Room Intern can be when all the scut work is being done by the Final Years, aka us.
One evening in Snappy, he tells me and Vinay that he is writing the UPSC Entrance Exam in a few days in Chennai and since it's on a Saturday, won't it be fun if Vinay and I pile on and make a holiday of it. This sounds like an awesome idea and with a pre-arranged taxi and a room he's booked in some Guest House, the deal is sealed.
We set off on the Friday before his exam and reach Chennai by 6. We check in to the room and find that there is one bed, not too big, and a quilt that is fairly thin and has 2 big holes. This could have sufficed had we been of average built but Pondicherry food and drink has taken it's toll, and bar Vinay, who it seems can never get fat, Rahul and I have increased our girths appropriately. This means that "tight squeeze" will be tighter than imagined.
There are no volunteers for the floor and it will be 3 of us, 1 bed and 1 holy quilt.

Holiday or not, Rahul does have an exam the next day and looking over his Admit Card, he suddenly discovers that a pencil is needed for answering and well, there aren't any between the three of us. So, we need to get a pencil.

So we take our taxi chap (booked for the entire trip) and set off for a general aimless sightseeing trip, and to find a pencil. Somewhere along the way, Rahul sees a big billboard put up by a Taj Hotel with pictures of crabs, lobsters and more seafood-"A special Promotion, Chef flown in from Hong Kong" and with a slightly muted shout of "OYE! We must go there", and totally against our better judgement and wallet restrictions, we direct the taxi chappie there.
We still don't have a pencil though.

We pull in and take in the plush 5 star lobby. The dinner is in the Chinese Restaurant and we walk towards it where we find a concierge kind of person just outside. He has a pencil which we borrow permanently.

The place is quite posh. Hushed tones, well heeled crowd, china and crystal on the tables and I am getting nervous. My wallet is not suited to this kind of place. But we're here, pencil and all and get escorted to a table in the middle. The menu arrives.
5 star prices. Wallets are checked for cash. We have about enough to cover some steamed rice (although I want the fried rice, but that's a bit too expensive), some boiled lamb (उबली हुई बकरी , in Rahul's words) and a giant crab. That's it. Anything more and we'll be washing the dishes.
The blame games start. We insist this was all Rahul's idea. He points out that we are here after all, and so we are equally to blame. Plus, we have the pencil.
Food. Rice is well, rice. The lamb is nice, and somehow expensive food always tastes better than the cheap variety. It has to.
The clincher is the crab. It's massive, occupying a whole plate and has arrived with a set of pliers, which is new to all of us. We call the waiter and specify that we would like the crab de-shelled. He returns a few minutes later and tells us that their "Special Hong Kong Chef" prefers the crab with the shell. And that's that.
The next 45 minutes are spent fighting the crab, eating whatever little meat comes out and convincing each other that it is awesome. To be honest, whatever we managed to pry loose from the shell was quite tasty but this was more of an unequal fight between a stubborn crab and 3 guys who had never used pliers on one before.
After 2 hours, we are still slightly hungry, but 3000 Rs later, no one is going to say so.

We get back, after our first 5 star adventure and decide that since Vinay is likely to use the least space, he should get squashed in the middle. He does, and spends the night with 2 arms poking out through the holes in the quilt.
The next morning, we drop Rahul off at his Exam centre and Vinay and I scout the local papers for any good movies playing and end up watching Independence Day in Dolby Surround Sound, popcorn and all.
Exam over (no comments from Rahul) and we set off back to our little village by the sea. Every time I come to Chennai, I feel like the village lad coming to the big city, and like the village lad, I long to return quickly every time. I'm a small town boy.

Pondicherry to me now means more Ortho and it is as mystifying as ever. I am petrified of the Ward Leaving and on the morning of the exam, I just skip it. I just don't go.
This, I should add, is completely not done. No one skips Ward Leavings. The marks are added for Internal Assessments, absentees are marked and it leaves a terrible impression. But I still don't go.

My first and last bunked Ward Leaving.
It doesn't help when I find out later that Manoj was looking for me during the End Posting and was pretty livid when he found I wasn't there. An angry Manog is best avoided but I manage to bump into him in Snappy the same evening where Shom, Rahul, Manoj, Bong and for good measure, Vinay (who hasn't even done Ortho), take turns about my unpardonable misdeed and the dire consequences this can have.

I spend some evenings in the loneliness that accompanies you when you're the only one who's bunked a Test or Ward Leaving.

But time marches on and it's Medicine next. 2 postings over. 8 more to go and then, it's Final Exams.
The future looks dark and deep. Not lovely.

Definitely not lovely.

Chapter 52-Deliverance from Deliveries

Jan 1997

I am now settling in to the routine that Labour Room is. Start at 8, work till 1 PM, lunch for an hour, work till 8 PM, dinner for an hour, sleep/work till 2 AM, then work/sleep till 7 AM...and so on. This is punctuated by an hour's bedside clinics in Wards 12 or 16 and that's the only time we prisoners are allowed to get out of here.

Dr RS is our Senior Resident in charge and is rumored to be quite close to Madam the Head. He's pretty OK actually, professional and all that, even feeding us some samosas and sweets one evening but we live largely in fear of him. One more such personality is Dr Anju, also a Senior Resident and coming to the end of her 3 year term. She is the seniormost of all the SR's here and one late evening, around 9 PM, when all is quiet on all fronts, she calls me to the SLR and asks me to dictate some names she wants entered into her OT diary.
So we sit there, me in scrubs and she in a Saree, me a slightly intimidated Final Year and she the "One with the Ear of the Dark Lord" with me reading out hard-to-pronounce Tamil names to her. I keep messing up the "ZH" sound in Tamil and after a few constant corrections, she turns around, all serious, and tells me that this incompetence at Tamil pronunciation, after 4 years in College, will have to be reported.
This was serious though she could have been joking. It's difficult to say.

The next morning, or rather really early morning, at about 4, while I am struggling with an episiotomy, there are frantic shouts from outside where someone has just thrown a fit. Eclampsia in Obstetric terms, this is quite an emergency and we rush out to find orders being shouted.
I start a line, not easy, and load up some Magnesium Sulfate, 14 g of loading, 7 in each buttock and then its more injections. I then have to wander across every so often to check tendon reflexes in the knee, a sign of possible toxicity. There is a whole room for these patients, just outside the CLR, and our job also involves keeping tabs on all these patients. So, when the CLR seems nice and quiet with no deliveries or impeding deliveries, there is usually some activity going on in the OT, the SLR, Eclampsia Room or when everything is genuinely quiet (a rare occurrence), some work is created for us.
Fill up the Birth Forms, Answer an impromptu viva, Do a Pre-op Round....We can't be sitting idle doing nothing...It's just not done you see.

The days are otherwise much the same. Deliveries, the odd panic in an emergency, lots of emergency Caesarians, some Caesarians which in hindsight could have been avoided, tension filled Morning rounds, muck covered babies, amniotic fluid all over the floor, blood here and there, lots of hands on placenta extraction and deliveries....routine.
I finally attend my first Section a few nights in. It's 2 in the morning, I've just arrived for my shift and am told to go into OT. This is my first ever time scrubbing and assisting anything and I'm tense as hell. Sections, even when not emergencies, become one when the uterus is cut. From here, it seems, the surgeon has less than a minute to get the baby out. And me, the greenhorn, is assisting.
We start, I'm supposed to give traction to the skin, catch some bleeders and generally be useful without getting in the way, the hallmark of a good assistant. It's not very smooth though, and my retractor gets a couple of raps from the surgeon.
"Hey, hold that thing at 45 degrees. Pull! Man! "
Then there is "Mop"...Or "Suck"....I keep mopping when I'm supposed to apply suction and vice versa. It's trying and traumatic but after a few minutes, there is a baby. Muck covered baby has arrived.
Oh the awesomeness!

The paediatrician has arrived too. A few taps and tubes later, the baby is handed over back to us and we get back into the CLR where I now have to write the notes and Live Birth Forms.
It's quite a kick to be honest. The scrubbing, the washing, wearing OT clothes, holding a retractor, cutting some sutures, seeing a Section that close. I should feel tired but the adrenaline has pumped me up. I feel energized and raring to go.
But with not much else happening, I sit and chill out, waiting for that dreaded phone to ring from the Casualty informing us of another walk-in in labour, an event that happens 24/7 all the time.

Another few days later and I have started resembling a zombie. 3 hour nights with constant mental and physical strain does take it's toll although I can safely say that now I can do a normal delivery pretty much anywhere. This posting is tremendous in what it teaches you, in terms of Obstetrics obviously, but also in time management, teamwork and stress management. This is also the posting where the basics of Patient Management are taught. How to start an IV Line, suturing, suture removal etc.

It's a fantastic posting but after 14 long days of no booze and little sleep, I'm dying to get out.
And just before we do, on the penultimate morning, where Narayayan and I decide to head for breakfast at 8 AM after a long, tiring night, hair dishevelled, clothes stained with fluid and blood, faces creased with exhaustion, we open the SLR door..
...and find 4 Consultants, led by Madam A, some Senior Residents, some Junior Residents, Interns and some sundry hangers on, all dressed in neat white coats, all in a long line,  all fresh from a good night's sleep waiting to start rounds.
It's awkward. We just bob heads, and slide quickly past, wondering aloud if this scene will have any impact on our Final Year chances.

But just like that, it's all over. At 7 AM, 5 of us troop out of Labour Room, considerably more skilled and armed with more practical knowledge than I would have thought possible. We are replaced by 6 of my batchmates, all looking as lost and apprehensive as we did 2 weeks ago.For them it's an unknown, mythical place. In us, the transformation is visible. I have a new found confidence in OG.

But boy, it feels good to be out.

The previous evening was spent in a short but deep discussion about Labour Room-what it is (a cramped, noisy, full on introduction to Obstetrics,), what the stress levels are like (very high), how is the OT ( same as anywhere but with lots of activity and is 24/7), the expected behaviour norms (refer Do's and Dont's) etc. There is a lot of underlying apprehension, anticipation and fear. Labour Room does that to you.

2 weeks later of Labour Romm later, we are expected to rush back to the rooms, quick shower, breakfast (some barely edible oily stuff) and run back to class as normal. Time, Tide and Classes, it seems, wait for no one. We have a lecture at 8, followed by clinics till 1, then more classes till 5.
This is all theoretical for me, since I have decided, falling attendance and all, to skip all of today and just sleep in. I figure I deserve it, after 2 weeks inside.
My clothes are giving off a faintly sweet, slightly pungent odor of amniotic fluid and have not been washed for ages. I feel like I've been swimming in the stuff for 2 weeks and I'm sure I'm giving off this smell too.  And boy, am I hungry for some Chicken Cecilia and Ghee Rice. All to be washed down with large doses of booze.

I really feel like I've achieved something major. I now know more Obs than most of my class. The problem I'm neglecting of course is that they know more about pretty much everything else. My Medicine, Surgery, Ortho and Paeds knowledge is abysmal. My Tamil is better but not enough to pass an exam yet.
All of this reality is pushed to the backseat as I take my bike to town after 14 long days. A few beers, a decent meal, some quality time with the sea and the crashing waves and much needed time just doing nothing. It's almost like Final Exams are over but I haven't even finished my first posting yet.

Back to reality the next morning and it's Clinics as usual in the OG Wards. We go to the OPD at 9, take a case, present it to the Residents and see a few Per Vaginals and generally look busy. By 11, we're off to the Wards where it's my turn to take the history of a Twin pregnancy, an important case for exams. I know what to ask, but I'm still getting stuck in the Tamil which is not a good sign, this being Final Year and all. A short while later, we are joined by the 6 who replaced us in Labour Room and looking at those still not-too-bone tired faces,  I am grateful that I am out of there.
Madam A comes to take our class. 16 of us huddles around the bed, all in gleaming white coats, all of us with pens poised on our small green note pads and everyone looking very alert and hoping fervently that no questions are directed at them. I start with the history taking care not to say that the patient is X years "old" and stumble along with minor road blocks. Examination time and I thankfully remember to warm the diaphragm of the stethoscope, drape the patient, get a screen and take consent. If this is not done, we have been warmed, one might as well not turn up for the exam.
Class over, I'm about to say a silent prayer for a job done without major trauma when she says (with a slight smile)
"Nishikanta, I heard you still haven't managed to speak Tamil properly"......
...and with her characteristic giggle, says "Good presentation"
and goes off.
What am I supposed to make of that? I have no idea. At least it's better than when Shom was in Final Year when she said "So Shomeshwar, reading hard, or hardly reading"? (and then the giggle again).
Shom spent a few evenings analyzing that moment.

The posting goes off in much the same vein and all too soon, the Ward Leaving arrives. My First Final Year Ward Leaving. 2 years back, in the same ward, I had given my first Ward Leaving and it was quite OK. My parents had actually thought that a "Ward Leaving" is a kind of party organized by the Department to bid us adieu. I wish.
This time, it gets more serious. We only have 2 postings in OG in the year and each posting is serious business. So is the Ward Leaving. 30 minutes to take a history and examine. I manage to do OK and pass. It's a boost of confidence but I know there are gross inadequacies, lacunae that can be exposed in no time at all in an exam.

I have my own "Ward Leaving" party in the evening, more on the lines of what my parents imagined and look forward to my next posting-Orthopaedics.

And every day is bringing me closer the toughest set of exams I will ever face-The Final Year Exams.

Chapter 51-The fruits of Labour

Jan 1997
9 days into Final Year
I am entering Labour Room tomorrow. This is a mythical place, a place where one can neither check out nor leave before our 14 day posting is up.  I, along with 4 others will start our posting at 8 AM sharp tomorrow.
I am excited, yes, but mainly apprehensive and a bit nervous.
I spend my last evening of freedom staring at the ceiling of my room, knowing I should be sleeping, but also knowing that when I wake up, I will be entering Labour Room.
It's a posting one looks forward to it, and dreads, all at the same time.

The Next Morning: 
There are 5 of us. We walk into the OG Corridor, past the Consultant offices and turn left opposite Ward 12, sharp at 8 AM, with white coats that will hardly be used, a textbook that will hardly be read and with stethoscopes that dangle authoritatively, either across the shoulders or straight down from the neck. Narayanan, Pakha Tesia (from Arunachal), Naveen, Pajanivel and me. The lambs walk down in silence.

There are actually two Labour Rooms. One is across from Ward 12 and is called the CLR or "Clean" Labour Room. Down the corridor and across from Ward 16 is the SLR or "Septic" Labour Room. Both are misnomers, I have come to realize, the CLR isn't very clean and the SLR is not septic. The names derive from the kind of labour cases that are kept there, with the CLR having normal non-infected cases and the SLR housing infected or potentially infected ones.
We walk to the CLR passing a room on the right labelled the "Eclampsia Room". This is a place which houses the Eclampsia or Pre-Eclampsia patients and a place I will be spending a few hours every day in. We also pass a few patients walking around or lying on the floor waiting to be called into the CLR. As a patient, one enters the CLR only when labour has started.
The 5 of us open the yellow fading double doors and troop in.

The Labour Room: 
One enters the CLR into a small rectangular area which has the onmipresnt OT trolley-an iron trolley with a mattress, off to one side, work tables, chairs, tons of papers and forms and a wooden clothes rod on the wall with hooks for clothes and OT green gowns. Immediately to the left of the main door is one of the Delivery Rooms whose entrance is marked by a biggish floor freezer which contains human placentae. There are 3 other Delivery rooms, perpetually full, each with 2 beds and all of them are next to one another in a line starting from the first one with the freezer. A Red Line with a marking "For Doctors Only" divides this area from the working rectangular area.
There is chaos here at 8 AM, or atleast that is what it looks like. In the middle of running nurses, shouting doctors and screaming patients, there is a calm Senior Resident, a guy about 5 years senior who has finished his PG in OG and is now posted in charge of the Labour Room. And in charge of us. Dr Singh greets us, we introduce ourselves and then there is a short lecture on the do's and don'ts of this place.

Some Do's:
1. Be punctual.
2. Work sincerely
3. Learn to learn on the job
4. Enjoy the posting
5. Go to OT and assist whenever possible

And some pearls like:
1. Always be in the Labour Room at 8 on a Monday. That is Unit 1 Rounds Day. Be seen working in the CLR when Madam drops in.
2. Never, ever be seen in the Labour Room without a green gown or an OT mask
3. Make sure the partograms are accurate and up to the minute.

Our schedule will be as follows:
Enter at 8 and work till lunch. We take lunch breaks in shifts, with 2 of us going at a time for a maximum of one hour. Then, its work till dinner, about 7 PM with shifts again. At night, 2 of us work till 2 AM, handing over the shift to the other two who will work till breakfast.
One guy gets the night off (8 PM to 8 AM) and this happens by rotation, so I'll be off for a night once in 5 nights. Classes are off except OG lectures and Ward Clinics. This is when we will troop in, looking haggard and sleep deprived, trying hard to stay awake during the Air Conditioned lectures.
Visits to the room during meal breaks give us just enough time for a quick shower, a change of clothes and a 5 minute gossip catch up session.
That's it.

One more thing: 
 When one retires for the night (in the Duty Room down the corridor, NOT in the hostel), one can be woken up at any time if there is a need. This can happen if the case load becomes too heavy, or if there is an interesting case being operated on or for whatever other reason. And one has to go.

We are shown the forms that we will be filling in the next 10 days. Live Birth Forms, Still Birth Forms, Death Forms. Investigation forms, from Bloods to Biochemistry. This is where I see these forms for the first time, the yellow Biochem forms and the Red on white Blood forms, forms that I will spend a LOT of time filling next year as an Intern. There are Ultrasound Request forms, OT "Call Slips", and Operative Notes forms.
The Call Slips, we are told, are sent when a patient needs surgery (usually a Caesarian here). It has patient details, when they ate last and what op needs to be done. The anaesthestist signs it and keeps a track so that they can "call' for the case when appropriate. It's a vital piece of paper. No Call Slip means the OT has not officially heard of the case.

We will essentially be conducting deliveries and doing all the stuff that happens around an imminent delivery, including monitoring, post delivery care, suturing wounds, assisting Caesarians, writing forms, and all and sundry. This is where we will learn to start IV Lines, take blood for investigations, monitor Oxytocin drips, do Per Vaginal exams, make out foetal heart sounds and know when the kid is struggling and when to initiate an urgent delivery. This is where we will learn to perform episiotomies-surgical incisions designed for easier deliveries and how to suture them back.

This is where we will be part of the miracle of birth.

We get a crash course in the later stages of pregnancy. There are 3 stages of labour. The first stage is a bit of waiting for the cervix to dilate fully. In this part, the patients are called in for quick regular checks to see whats happening with the dilatation and if something needs to be done. Once that is over, the second stage starts and that is really where we come in. Monitoring starts intensively now, with Blood Pressures, pulses, foetal heart rates, foetal positions (is it coming down properly or has it got stuck), various drugs to be given to speed things up etc. All of this monitoring is recorded on a graph-the partogram, which is stuck on the wall next to the patient and is inspected regularly by the Senior Resident, or rather more importantly by Madam A or the other Consultants when on rounds. Failure to maintain a proper partogram is a recipe for disaster in exams.
Such foul-ups are remembered.

There are 10 full days of this and how one survives depends a lot on how one takes it. It's there and has to be done. The knowledge that one will acquire, actively or passively will be tested severely in exams and even if one fails to answer some intricate question in Obs or Gynae, lack of Labour Room procedures is a sure way to instant doom. Ears have to be perked up, eyes have to be peeled, brains have to be alert and feet have to be quick.
A normal delivery is fine, but a complicated one can turn nasty very fast.

It's the first day, the first morning in fact and I, like the rest of my 4 classmates, are like babes in the wood. There isn't much time to settle in though, as the action starts off pretty much instantly. It would be fair to say that the action actually never stopped, we just happened to be a brief interruption and are caught up in it, stat, as doctors are wont to say.

Except that we are now saying things like "stat" and "IV Line" and "Synto drips" and Magsulf" but are nowhere near being called doctors yet. I put on my green OT gown, hanging on the wooden gown holder by hooks, and put on my mask. The others do the same and we are allotted "Delivery cubicles" and patients to monitor. Our task for the moment is to chart the progress of labour on partograms, as accurately as possible and hope that it turns out OK. The problem is that, in an ideal world, we would monitor these patients from start to finish, ending with a newborn baby in our arms and saunter off for the next one. But this is Labour Room, where on an average, I see from the huge Delivery Record Register, about 40-50 deliveries are conducted every day (and night).
So, in reality, the morning is spent monitoring one patient, rushing off to attend a delivery for another, starting an IV line for the third, running back to the first one to measure contraction durations and foetal heart rates and writing up Live Birth forms. I learn the core of any busy medical practice-how to mentally compartmentalize many patients and keep tabs on what is happening to each.

I am in charge of a patient who has just walked in for her delivery. I start an IV Line, get some bloods for baseline work-ups and off we go. I start a Oxytocin drip (Synto) and start counting drops. First 4 drops a minute, (very painful to count), then slowly, after a vaginal check has shown the labour is progressing well, I increase it to 8 (still painful to count). The patient is a "Primi"-first kid, so this is going to take some time. In the middle, someone comes along and applies some "Epidosin" that is supposed to get the cervix to dilate and efface properly. This is done thrice, 15 minutes apart.

While I am counting contractions and synto drip drops, a shout comes from next door.

My first delivery is rather uneventful. A typical "Mutli"-now in her 3rd or 4th pregnancy, with the foetus in the normal "OP" (Occipito-Posterior position with a Longitudnal lie) is having solid contractions spaced about a minute apart, each lasting for about 45 seconds. A vaginal examination has shown a nicely dilated cervix and a full on shouting match is in progress.
It's the battle cry of Labour Room
"Mukkkkkkk Maaaaa"....."Mukkkkkkkkkkk".
"Push Ma...PUUUUUSSSSSHHHHHHH".......
With every contraction, the above shouts happen.

After a few minutes, the head shows (crowining).
At this point, the patient is in agony also and is screaming her head off, so the noise levels are pretty high.  Then suddenly, the baby is out, all covered in muck and is quickly delivered, wiped and the umbilical cord is tied and cut. The baby is whisked off to be checked by a Paediatrician who has been hurriedly summoned from somewhere and the sudden cessation of noise is ghostly. The sheer relief on the patient's face is obvious.
The job is not over though. I have collected some blood from the cord in a small "Penicillin" bottle which goes off for blood grouping and I now sit ad wait for the placenta to come out. This is helped along by carefully pulling on the cord, almost as if not pulling at all, but just about in a manouvere called "Controlled Cord Traction". That done, we inspect the placenta for bits that might have been left behind and then (probably) proceed to dump this placenta in the freezer next to the main door.

In the meantime, the others are also at work, running about with various tasks. There really is no "allotted patient". Whoever happens to be around at the time a delivery is going to happen assists or conducts the delivery. We all have 10 deliveries that we must conduct independently and write in our Records and it seems like we will reach our targets on the very first day.

Lunch time happens, all too fast and we take turns. One guys has vanished into OT for an Emergency Section (Naveen who will soon develop an OT fixation) and I, along with someone else go for lunch. It turns out that going out for lunch or dinner in the first shift is not a great idea because one has to be back in 45 minutes to relieve the other two. On the other hand, if one goes later, time can be stretched.
One can go out of Labour Room for various things. Sometimes, it's to collect a Biochem report from the Lab on the 2nd floor. Or to pick up a form for something on another ward. Maybe to get the portable ECG machine lying around somewhere or some such thing. If one goes for lunch second, all this can be combined with the lunch break (mostly fictitious outings). Since there is no pressure to come and relieve anyone of us, these breaks may even last for an hour!

My Primi patient, meanwhile has reached 16 drops and is doing well. Screaming like crazy, which is good, and has good Foetal heart sounds. I place a hand on the abdomen during one contraction and I can feel the normally soft, flabby skin turn rock hard for a while. The patient knows this too and starts moaning a few seconds before the contraction hits, the decibel levels reaching sky high for a few seconds. It's said that Labour Pain has been ranked 10 on a Pain scale from 1 to 10 and I can see why. There's a baby squeezing hard inside.

I am keeping track of the labour on the graph and a Resident is doing regular vaginal checks on the state of the cervix and the descent of the head of the baby. At any point if the head gets stuck and labour does not progress, the whole thing may have to be cut short and expedited, either with instruments like forceps or a vacuum pump or by a Caesarian Section. In this case, things sail smoothly and towards the end, I am taught how to make an episiotomy incision.
"LMLE". Left Medio-Lateral Episiotomy is what it is called. One gloved hand in the vagina and after some local anaesthetic, a 6-10 cm cut is made to make more room for the baby to come out. The baby is out, and after the placenta thing, I now have to suture this freshly made cut.
I see someone doing it first. Three layers, muscle, mucosa and skin.
"Identify the apex".
Take continuous sutures".
"Three layers, interrupted for muscle and skin".

...and remove the tampon!! (If one does not say "remove the tampon" when one is asked "What will you do after suturing an episiotomy", one fails the exam.

It is fun. Exhilirating. It does feel awesome to hold your first delivered baby, muck or not. All the cliches about awesome feelings and getting overwhelmed are all true, else they would not be cliches.

I still have not seen the Eclampsia Room or the SLR and it's already dinner time. I will go second this time...

...................................................................................................................................................................

It's been a very long day and it's difficult to digest that we've been here for about 12 hours only. There are 13 more such days to go and of course, since babies have no regard for tired doctors, 13 nights too.

But it's been pretty exciting.

It's also been a bit terrifying. In Labour Room, all our activity (or lack thereof) seems to be monitored, even when it seems like there's no one there watching you. Break times, time taken during those break times, partogram charting, accurate monitoring of the soon-to-be-mothers, whether one is wearing gowns, caps and masks....all of it. There is a Labour Room Team consisting of some OG Residents and led by a Senior Resident, all of whom can report to the Head and thus perhaps earn brownie points. Or maybe we're all getting paranoid.
She (the Head) also likes to pop in now and then and it's in everyone's best interests to be busy at those times.

In any case, after a day of deliveries, the odd panic attack, screaming mothers and crying babies, clothes with the faint smell of amniotic fluid and frozen placentas, it's time for dinner. When posted in Labour Room like we are, the door of the Labour Room is almost like the door of Hotel California.  After 12 straight hours, it is beginning to get oppressive and when 2 of us take the first shift to go have dinner at 8 PM, we stay back, doing the usual Labour Room thing but in reality, looking constantly at the wall clock waiting for 9 PM to strike.
We also make a sleep schedule for the posting. 2 of us will stay on till 2 AM and will be replaced by the other 2. One person will have a Night Off every 5 nights. This system is pretty standard but the nights can get unpredictable and if there is a "good case", all of us will be expected to be there. The usual scenario is a complicated delivery or an Ectopic Pregnancy requiring urgent surgery. One hopes that it doesn't happen in the sleep part of the shift.

Dinner at 9. The feeling is liberating, even if for an hour. It's also great to go back to the Hostel because for many people, the Labour Room is a mystery, almost a mythological place and strutting around a bit is normal. In the beginning at least. Snappy is open and after a quick shower, I park myself there and find Rahul (who's already done this twice and is not interested in talking about it) and Vinay (who will go in about 2 months time, could not care less right now and is also not keen on a Labour Room chat) and so, inspite of dying to relate my exciting new experiences, we talk about some usual nonsense.
The minutes pass too fast. I am back inside at 915 and will go to sleep first.

Except that it's not so easy. When one is used to sleeping at 1 AM every day, 930 is too early for the body's clock to switch off. We go down to the Duty Doctor's room and bunk in one one of the 4 of 5 iron cots kept there.
This is my first experience of sleeping in hospital, the first of many obviously. For one thing, when I am woken up at 2 AM by my colleagues, I am in a sleep deeper than pretty much ever. However, I am also able to get up immediately, face washed and ready for Labour Room action in the span of 5 minutes. It's a paradox that will happen, on every night spent in hospital.

Quick notes are exchanged. The status of the Labour Room, who is expected to deliver soon, any Ceasarians planned for the night, how many deliveries waiting outside..all indicators of how peaceful the night is going to be.

Slightly groggy, we troop back to find relative peace and quiet. Half the team is in OT with 2 more cases lined up for surgery and not much else is happening.

This is still the first night and it passes off soon, periods of minor activity interrupted by visits to the shacks for some coffee and nicotine. It feels kind of senior and old to be in Stethoscopes and Aprons at 4 in the morning and it's not altogether a bad feeling.

Soon after, it's 730 AM. Time to wake up the others, get ready for rounds at 8 and for another day here. I'm getting used to it but there are still miles to go...