Chapter 61-The Final Postings of my Student Life

Sep-Oct 1997

August is a month of mixed emotions. I want to see Interclass, see Spandan in all it's glory, bask in my filthy room and get awarded for it again, and like the rest of the campus, just take a break from the drudgery.
Instead, the spectre of exams is haunting me in my dreams and it's a race to the finish line, with no real guarantee that the race will be over.

Paeds drags on-kids with chests to be auscultated, abdomens to be palpated and developmental milestones to be mugged. OP Ghai, my standard issue Paeds book is completely unmarked and unread except for the section on heart murmurs which I read in Medicine, not here. My classmates discuss what's good in the book and what's better in Nelson (a huge Post Graduate book) making me feel decidedly incompetent and inadequate since I can't contribute to the discussion at all. At this level, a lot of Paeds is like Medicine for kids and I figure that by reading some Medicine, I can get by with Paeds in the exam.
The ward leaving comes and goes and we move to Medicine.

The Medical wards are on the top floor of the hospital. I've climbed the steps to this floor countless times, at times stopping briefly at each landing to admire the painting on the walls, all signed by a "PK Patra", all done in the '60's. The stairs open in front of Ward 41 across which is the Dialysis Room. Leading left is a long corridor with all the other wards-43 being the subject of much debate in particular. This ward, which is now a CCU, started life as a RICU (Respiratory Intensive Care Unit) which promptly got the Chest Diseases Dept to stake a claim on it. The RICU was a brainchild of the Anaesthesia Dept however, and so they renamed it and now it's their sole baby.
I've been here once and it looks pretty state of the art. Last year, while reading for my marathon 5 paper exam, Vij, a PG on Obs/Gyn had asked me to donate some blood for one of his patients admitted there. It was 3 AM, I was bored stiff and I willingly obliged. I went to see the patient here that time and there she was, lying alone in the quiet pale blue light with tubes and wires, monitors beeping, sedated, or probably, unconscious. She had DIC and her chances were slim.
She died a day or two later and it affected me a for a while before life, and I, moved on.

The rest of the wards, like all in the hospital are numbered in sequence and on this floor, the Ward at the end and to the left  is occupied by the Plastic Surgery Dept. Manned by Dr KA (whose wife is a Consultant in Medicine and specializes in long, silent, uncomfortable stares after asking a question) and Dr P, this Dept is almost like a hospital in itself. It has it's own Record filing system, meticulously kept and religiously maintained complete with pre-op and post-op photographs. Dr KA has a reputation of being an excellent surgeon, specializing in cleft lips and palates. I've often seen the couple walk around the campus at night and I'll be dealing with Dr AA, his wife in the coming weeks.
Dr AKD is a gem. He is the Head and is a short, sweet guy although I hear that he can be hard on his Residents when needed. By all accounts, he is a boon in exams and we all start praying he comes as examiner.

The posting is like any other. We start in the OPD, move on to the Ward where a case or two are allotted and we take turns to present these to the designated Consultant/Resident. This varies from day to day depending on the Unit that is in charge of the case. Like Surgery and OG, Medicine has 4 Units and each Unit takes turns to allot and take class for us.
This drags on-heart lesions, lots of TB and pleural effusions, ascites and fluid thrills, pulsating abdominal masses, enlarged livers and spleens, strokes and facial palsies. It's a very long list and we are told that really, there is no defined case list at all. Anything can come, it's just vital to examine systematically and arrive at a working diagnosis. As long as that can be justified based on history and findings (which must be accurate of course), the odds of passing improve dramatically.

This sounds simple in concept but there are many, many roadblocks. I hear of a someone, a topper, who found a lymph node and made a diagnosis that could have only been made with prior knowledge of the case. His history and examination were top notch, but he failed. My hearing has become selective. Instead of hearing success stories, all I can think about is who failed in previous exams, why they failed, how they got unlucky, which examiners were "lousy" (or "bastards"), how tough the exam is and how exotic some of the questions can be.
Pondicherry is an alcohol haven and once, while driving to the bus stand at 7AM to book tickets, I saw an open booze shop and a lone cyclist, probably a worker in one of the many factories, cycle along to the shop, order a peg, gulp it down and speed off, all while still on the bike. It is no surprise, therefore to find so many cases of cirrhotic livers and distended abdomens, enlarged livers and bleeding varices.
I have thought about my own liver occassionally but the standing joke is that one must get the liver enzymes to work regularly by imbibing enough lest they fall into disuse atrophy. And I have kept them busy.

It's an uneventful posting. Nothing has changed from the last time. Dr RP with his "Diagnosis Doctor!!", preceded by a long diatribe in incomprehensible Tamil, his shotgun approach to Medicine, Dr KRS with his stern, professorial looks and fantastic diagnostic acumen, Dr TKD with his reputation of being fair and impartial in exams and Dr AA with her silent, uncomfortable pauses between questions. Classmates reading fervently, me looking a little lost, patients being examined multiple times and probably suffering in silence, the usual feeling of doom and gloom and the odd panic attack.
The subject is so vast that I really don't know where to start. Some have called Medicine "Intellectual Masturbation" but I don't feel particularly intellectual right now. Reading has to be done however, so I read Davidson, mug up the thousands of signs and symptoms in PJ Mehta, read all the notes I can and listen to all the classes in earnest. These are the last few classes of my MBBS days and each one can make a difference.

The days pass by. Interclass and Spandan whizz past. I hardly see anything and in the few events that I do manage to see, I feel guilty after half an hour and go back to read. Spandan will be back next year, when I will hopefully be an Intern and I can devote all my attention to it then.

For now it will have to wait.

October 1997

It's all come down to this. My last 4 weeks as a Medical student. Surgery is my last posting and will finish 2 days before my Send-Ups, the full scale dress rehearsal Exam before the Univs. By this time, all I am doing is reading. The reading, of course, is punctuated by lunch, dinner, classes and the odd Snappy excursion but it's all about reading now. I feel comfortable with OG and most of Surgery but Medicine and Paeds remains a problem,especially the theory simply because of the size of the subject. I have to focus now on Surgery however, in these last 4 weeks of my student life.

Surgery has logic. There are visible things to examine-ulcers, swellings, breast and thyroid lumps, abdominal masses, varicose veins, hernias and hydroceles. There are well defined points in the examination of each of these and at the Undergraduate level, fairly structured treatment plans and options that we need to know. I like Surgery even though the smell of infected ulcers and cancers of the penis can drive one straight to the loo. Surgery, however, does not like me. About a week into our posting, some of us are called into Prof AK's Office. There are about 6 of us and we are called in separately. When the first guy goes in and comes out with a worried look, some rapid, urgent questioning reveals the problem. It's attendance.
Sigh.

I'll never come to terms with attendance. The college requires 75% and this can be condoned to 65% with a fine. Except for Pharmacology where I landed up with 64.6% and therefore 1 class short, getting stopped from writing the exam in the process, I have managed to make it through each attendance related potential disaster. I have even done well in exams so far aggregating about 69% in the Univs. I hate attendance as a criteria for writing an exam but rules are rules and I am probably short again in Surgery.
I walk in. It's a fairly bland office with the usual cupboard of books and journals, some furniture, a tubelight and an examination bed and green screen.
Prof AK, with his ultra-dignified looks and horn rimmed glasses perched on the bridge of his nose, peers down at me, standing nervously 6 feet away.

I have imagined this scenario happening to me. In previous years, it has happened to a few of my seniors and they gave me this wonderful piece of advice:
If told that you are short of attendance, tell Prof AK that you will make it up by attending Casualty posting during your study break.
This worked for them and they were allowed to write the exams.

Prof AK is serious. He has a paper open in front of him and quotes exact figures of my theory and Clinics attendances over the past 3 years. They are not flattering but not that bad either. I am both a bit amazed that I attended so much and a bit upset at myself for not attending enough.
So I quote Shom's gospel.
"Sir, I am truly sorry but I promise to make it up by attending Casualty posting in my study leave. I 'll go every day for however long you want me to go"
Prof AK gives me long look, no smile and in a firm, even, almost fatherly tone, says
"Look man. If you attend classes in the 14 days of study leave you have, both your numerator and denominator will increase. Your attendance percentage will hardly increase. So there's no point doing that. I can't allow you to write the exam".

I come out. I've given up now. I don't care about the exam itself. What I'm worried about is how I'll convey this news to my parents. They took it well the last time and I wiped that memory off with my best performance in the subsequent 5 paper exam. That was then and I am now in the same situation. It's frustrating and depressing. Of course, I have only myself to blame.
5 months earlier, a notice had been put up stating that all of us needed to pay the 400 Rs or so of tuition fees for the year by a certain date. I read it, saw that the date was a month or two away and forgot about it. The deadline passed, another reminder, complete with warnings about "Name removal from the Register"  came and went and my fees remained unpaid because I forgot to tell my parents.
In class a few days after the second deadline, my name is not called in Attendance. Thinking this has to be an oversight, I walk up and find that my name has been witheld owing to unpaid fees. To make matters worse, the College has sent a letter stating exactly this to my parents who, I imagine, would have been less than amused to read about their son, in a far away land, not paying the token fees simply because he forgot and has got his name removed from the Register.
The matter is remedied quickly after an awkward phone call home. Now another much more awkward call may be required.

There is still hope. Historically, no one has been stopped from exams in Surgery because of attendance. The fall-out of my one-on-one meeting with Prof AK is that he now knows me quite well and is well aware that I have attendance issues. This has put extra pressure on me to do well in the upcoming Send-Ups and I HAVE to pass this. I get the feeling that if I fail, I won't be writing the exams.

The posting drags on. I haven't yet seen a Varicose veins case and I'm worried. Varicose Veins involves tying tourniquets at defined points on the leg to see which veins fill and which don't. The idea is to locate the perforators and see which are patent. It sounds simple enough but I know that unless I see it, or better still, actually do it myself, it will be very difficult to suddenly do an accurate examination in the pressure cooker atmosphere of the exam.
There is a Cancer of the male breast somewhere in the Wards and we make a beeline to see it since it is rare and so will definitely be kept in the exams. The problem with Breast Cancer is that the treatment for each stage is unclear. We have been told many different things for each stage and it's very confusing. We approach Prof AK for a class, having been told that he often takes lecture classes right at the end to clear up really tricky issues.

The class is wonderful. Breast Cancer has never been clearer. He even explains Estrogen Receptor measurements (in fmoles/L), takes time to answer all our questions and just demystifies it completely.
Then, this happens...

Normally after a class, the teacher calls out attendance by name which is entered into the register as either an "A" or a "P". Some of them choose to pass this register around and we mark ourselves. This is rare however.
Prof AK passes the register. This has happened with senior batches and Prof has a reason. The register starts from the bottom row where the front benchers sit. The register has the entire attendance from the start of 1st Clinics. In theory, all the "A's can be overwritten to "P" and for the first two rows, the register passes quickly, first because Prof AK is 2 feet away and second, because this group of people probably do not have attendance issues anyway.
The drama starts after that. The register is passed very slowly, each guy taking time to overwrite as much as possible while desperately trying to hide this from Prof, standing and waiting for the return of the register. There is much tension because we know that at any time he can call for the register and some of us might get left behind. The register is almost snatched from one another and by the time it reaches me, I barely have time to overwrite as much as I can, and to anyone it will be quite obvious what has happened. After a while, bored of waiting Prof AK calls for the register and walks off.
There is an audible sigh of relief.
We later learn that he does this for every batch for whom he takes a last effort class. We had been warned
"Bugger, he will circulate the register. Make sure you get your hands on it"

A few days later, with the posting nearly over, the Dept posts the Attendance list. I am at 82%. I know that not of all this increase is because of me and the register.
He didn't have to do this, but he did, knowing that exams are round the corner and that's the best place to expose knowledge lacunae.


Send-Ups: 
2 days. 2 days in which to revise nearly the whole of the last 4 years. There will be a theory paper in Medicine, Surgery and OG. This will be followed by Clinics in those subjects with a short case in Paeds and Ortho as part of the Medicine and Surgery exams respectively.
The structure is thus:

Medicine: 
1 Long case-45 minutes to examine and write a case sheet
1 Short Case-15 minutes for examination
1 Paeds case-20 minutes for examination
A bedside viva in each
This is followed by 2 spotter diagnosis and viva on them, a viva on microscope slides, instruments and ECG and a drug viva.

Surgery: 
1 Long Case-again 45 minutes
2 Short Cases-20 minutes total
1 Ortho case-20 minutes
A bedside viva in each
This is followed by vivas on Operative surgery, surgical specimens, instruments and X-Rays and  general theory viva.

OG: 
1 Obs Case-30 minutes
1 Gyn Case-30 minutes
A viva for each case.
This is followed by vivas on Insruments, X-Rays and a Normal Delivery demonstration with a dummy baby and pelvis.

The real killer is the Long Case. It carries 75 marks out of 150 and in 45 minutes, we have to take a detailed history, examine completely, get a diagnosis and then write all of it down. In the case presentation, whatever we say is matched with whatever is written. If something is not written, it is assumed it has not been done. It's vital to write a good case sheet.
The short cases do not need a case sheet. But that makes it trickier because one must then present logically from memory. Examination findings are key here.
In general, if one does well in the cases, the later vivas do not really decide the Pass/Fail result. However, one has to pass separately in Theory and Clinics to pass overall.

My Send-Ups do not start well. The Medicine paper, as expected is not good. The rest I manage well. I am particularly nervous about Surgery Clinics. I need to pass this because even after all the attendance register shenanigans, I'm not sure I'm out of the woods yet. The Long Case has a hard mass in the umbilical area and I don't know what it is. Dr Benjy, my examiner kind of half nods, half shakes when I venture "Ca Stomach" and I walk out not knowing what just happened.
Prof A, the head of OG comes for my OG Viva. This can be make or break time especially if she decides to come for our University exams as well. She is sweet, the vivas are great and I walk out feeling much better about life.

The results are announced. I fail Medicine. I get 75/150 in Surgery. I pass!
OG is a breeze.

Surgery puts up the final atendance list on the notice board. I am at 82%. No one in the class is short.

I'm nearly there. My study leave starts now. Univs are in 12 days.

Chapter 60-Sastri, Interrupted

July-Aug 1997

For a fresh batch, the Jipmer academic session usually starts on the last Monday of July. I had joined on the 11th of August 4 years ago, which meant that I had missed 2 whole weeks of Anatomy, Physio and Biochem-at the time seemingly insurmountable gaps in knowledge, remedied eventually by hard core last minute cramming, helpful seniors and BD Chaurasia, that saviour of all Medical students in Anatomy. Over time, as one moves through the course and becomes more senior in the process, the terrors of getting ragged and reading that joining as a Baby Junior bring are replaced by the joys of doing the ragging, with reading now having being reduced to a necessary evil in the scheme of things. While it is not true that a medical student has to study ALL the time, it is probably true that they need to study more than anyone else, in more ways than anyone else and with more pressures and lesser rewards than anyone else.
The reading has become a part of life. The ragging and the anticipation of meeting fresh baby juniors, however, straight out of school and into the big bad world, is very real and comes around only once in a year.
August is the "Silly Season" here. It is the month before Spandan, the month of InterClass, Hostel Days and the month where, within the unwritten code of Jipmer ragging, the raggers can have a field day (or month). It is also the month where the Jipmer Students Association (JSA) screen the Jipmer Film Festival.

The Festival lasts for 3 days and consists of non stop movie screenings in Hunter or Bernard Theatre starting from about 5 PM till whenever the last movie finishes, sometimes by 3 AM. It's back to back, tickets are at 5 or 10 bucks, movies are projected onto a big screen and it's a time to catch up on lost movies and sometimes-hard-to-get juniors.
So we shall sit in AirConditioned comfort sans the accompanying booze and nicotine. The theatres are located on the Ground and first floors, at the end of a corridor which starts off at right angles from the Main Hospital entrance. The corridor leading straight on is the OG corridor on the ground floor and the Paeds/ENT/Ophthal corridor on the first floor, with a ward at the end reserved for Surgery.
The ground floor corridor of OG is a long one, starting near the Main entrance and ending at a T Junction with the Psych Ward on the Right and Private Rooms on the Left. However, it's actually more like a crossroads with the Hospital effectively ending here and the corridor, now continuing on, leading to the Hospital kitchen area, complete with the smells of freshly cooked Sambhar. There is a way to Aschoff House from the kitchen, although to get here, one has to leap across a wall and walk through some bushes and trees. Aschoff, of course, is where all the juniors now stay, safe from the terrors of meeting seniors in Lister and Osler, an exercise in isolation from which I was thankfully spared.

These days are small welcome breaks from all the academic tedium, especially for us Final Years, who do not benefit from the respite that Spandan confers to the campus. Everyone will be off except for us and we will have to go to Clinics from 9AM-1PM while the rest of the campus entertains and plays host to the 4000 odd Spandan delegates. This is actually fine and for 2 reasons:
1. Clinic attendance is vital to passing exams. One missed Clinic may mean a missed exam case.
2. The Final Years have organized Spandan etc the previous year.With that, their role in Spandan reaches a zenith and when it's over, they hand over the reigns to the next batch and move on.
The party is over, so to say.

I have seen some of the new juniors and there has been no real time to rag anyone. I have heard of a particularly cocky behaving guy called "Sastri" whom I haven't really met but has been pointed out to me from a distance. He walks with a slight swagger, and thinks he walks the walk and talks the talk. This kind of attitude is fairly common among uninitiated juniors and one of the aims of ragging is to get them back to Mother Earth.
It is therefore, inevitable that I say "Hey bugger" when I see Sastri in Hunter Theatre just before Batman and Robin is due to start.
He saunters up the step to me and says "Yeah, what".

I should have caught him by the collar, dragged him down the stairs and into Lister House, tortured him all night and dumped him back in Aschoff. But I am beyond all this, too tired, too senior and too bored. Sastri, from what I hear, is already a marked man and I suppose the rest of the lions will feed on him at some point.

The movie starts. It's one of the worst I have ever seen. Sheer stupid torture. It's dark but I can make out Sastri sitting on the front benches with some other babies. I'm getting the impression that the movie, horrendous as it is, is just an excuse for people to get closer together in the dark. In any case, around 3 AM, with the movie drawing to a close, I see Sastri suddenly leave, quietly and quickly.
This can mean only one thing. Our man has decided to cut and run, bypassing the hordes of frustrated and bored seniors in the theatre who will undoubtedly make him their entertainment for the rest of the night.
I am bored too. And I know exactly where he's going. I rush out into the corridor and see Sastri walking fast and turning into the OG corridor. This means that he will take the short cut to get to his room in Aschoff, again not risking getting caught by anyone. I won't be able to catch him, what with me being fatter, older and with less able lungs but I have a bike. I jog to my bike, gun it and get to Aschoff House. 5 minutes later, Sastri emerges from the trees in front of Aschoff and stands in shock. His escape to freedom has just been short-circuited.

"Hi bugger, where do you think you're going"
...Silence

Hoping to run away and go to sleep, Sastri is instead met by me, a Final Year student fed up with books, vivas, classes, attendance issues and longing for some entertainment. Sastri and I, however, end up just chatting. He is a bit in awe of how I saw him escape and cut him short and how his jaw dropped when he saw me, standing between him and sleep. It turns out that he's from Bangalore and interested in Neuroscience  He wants to do Neurosurgery apparently, preferably in NIMHANS. (My eyes roll here. This guy is about a week old in MBBS). He seems smart which may not be the wisest thing to be in ragging season and I tell him so. Talk veers around to books and he tells me he reads a book called "Stryer" for Biochemistry.
I know this is rubbish since Stryer is unreadable, massive and not even recommended. Maybe he hasn't discovered this yet.
He has made the fatal mistake of expressing an interest in basketball and will be recruited for the team. His classmate, Muneer, has also done the same. Both will spend the first year running laps around the field, doing German drills on the court, fetching water for the big boys and despite being treated like dust, will develop an attitude and swagger that everyone on this team manages to do.

It's now 430 AM. Sastri and I go out for tea in the shacks. I think he's a bit relieved that nothing more came out of his aborted attempt to escape. I feel good too-in Jipmer lingo, a typically "jobless" thing to do. Chasing juniors at 4 in the morning.

The joys of College, Final Year or not.

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.