In Siddhartha, Herman Hesse’s classic, the protagonist says that thoughts do not ever come out as they really are when put down on paper. In scientific terms, this is known as corruption. Not the corruption that is rampant in the social fabric of post independence India, but a far less damaging term that refers to the pen and paper equivalent of Chinese whispers. It is amazing how a message acquires unintended tones and colours during its passage across several human beings, and so also – a thought. The journey of thought to paper and then on to another’s brain, is one that is fraught with peril. I should therefore, clarify at the outset that, if some parts of this article seem a bit unpatriotic, it doesn’t quite reflect the inner feelings of my heart. What is true is the yearning for a better mindset amongst Indian patients.
From 2012 onwards I had been making forays into the Arab heartland. Mostly, the nature of the trips was for free consultations and reconnaissance, to study the people, the market, and the mindsets. I often used to lecture to the doctors in Oman, either on a private basis or through the good offices of the Sultan Qaboos University Hospital. Teaching younger surgeons and undergraduates is always a pleasure – as your shadow starts lengthening with the onset of the evening of your life. Moreover, I had started performing a huge series of bariatric surgery operations in the Sultanate of Oman, under the helpful wings of my cousin, Dr Raman.
This story is about one such personal experience, one of a cluster of events that made me love the Arab mind.
It was 11 PM on a Friday night, and I had just finished a long list of free consultations. Friday being in the Middle East what Sunday is for the rest of the world, the staff that populated the hospital were few in number, the rest using the weekly holiday to stock up on their rations, and catch up on their meagre social activities. I got a call in my consultation chamber, saying there was a lady in the casualty, brought in with severe pain in the abdomen.
Right away, I zipped over and saw a young woman, probably 20, struggling with pain, her moans and whimpers of severe pain resonating around the casualty. With her, was a man well past middle age, probably the father, who looked equally distressed. #A brief description here of the average Omani male. Contrary to what has often been portrayed by English literature, the average Omani Arab is an exquisitely sensitive, concerned human being. He is not a classic male chauvinist, although he often has several wives. Women are given a lot of respect in Oman, and it has been royal decree, that in all matters, the fair gender should be given maximum consideration. Consequently, one can often find lady drivers (no, that’s the same as described in Western literature) overtaking from the wrong side with a honk, whilst the overtaken male driver would meekly submit to Fate’s larger design.
Seeing the lady writhe with pain, and being cognizant of her father’s distress, I quickly rushed into action. Swearing obscenities is almost a knee-jerk reflex of most surgeons. I’m not proud of it. But that’s what we do. In an emergency, when every nerve and sinew is straining to overcome the crisis at hand, only those nerves and muscles that make up that ever mobile, emotional upstart, the tongue, go on a rampage. The most holy headed surgeon, in an acute crisis, will have the fluency and content of language that a Billingsgate dockworker would feel intense familiarity with!
So there was I, barking orders to the nurses,organising a large dose of analgesic (painkiller ) into her, and eliciting a quick history about her problem. Not talking to a patient will often hide from the clinician, vital facts that would significantly impact decision making for that particular crisis. Reassuring her about pain, and organising the needful basic injection for quick pain relief, I had a quick chat with her, and learned that she was pregnant. She was told by her obstetrician that she had an ovarian cyst, at the time of the first pregnancy scan.
Ovarian cyst complicating pregnancy is a relatively common occurrence. The rich hormonal output during early pregnancy sometimes causes fluid filled bags, or cysts, in one or both ovaries. Usually the doctor’s reassurance is sufficient, and a friendly pat on the back and a rub on the shoulder are all that’s required in the management of the garden variety of small cyst.
Her obstetrician had done just that, and rightly so. However, the winds of uncertainty tend to blow through every available nook and cranny in the field of medicine. There is a beautiful saying, “never is never right, and always is always wrong“. One just doesn’t know when a lump in the breast, appearing simple and benign, can actually turn out to be a cancer. Many times, clinicians are caught on the wrong foot by such a freak occurrence. Similarly, one doesn’t quite know when a cyst can turn naughty. In this unfortunate young (and pregnant) woman, it did.
On gently palpating (running a hand over) her lower abdomen, I was just about conscious of a fullness on the right side, which was giving her severe discomfort. Her uterus itself was enlarged, but seemed to be normal to the touch. The rest of the abdomen, on palpation, seemed very normal.This is an important finding. One of the most terrifying events in early pregnancy, frightening for patients and doctors alike, is the ruptured ectopic.This is the sad implantation of the embryo, not in the wall of the uterus, as it should be, but in the Fallopian tube, whose purpose is to merely bring eggs from the ovary for fertilisation. After growing quietly within the confines of the tube for the first few weeks, many ectopics will rupture into the belly of the patient. As large blood vessels surround and encompass the embryo in order to bring vital nutrition to the growing mass of child cells, rupture of the ectopic pregnancy invariably causes steady and dangerous bleeding into the peritoneal cavity, or the abdominal cavity of the patient. Blood being an irritant (ask many a man who fought with his family members, and he will aver. Perhaps, it is not without reason that the Bard wrote, family is known as Kin because they are more than kith, but usually less than kind!) shooting back from the stream of consciousness – joycean drivel, blood matters…When a large amount of blood is spilled into the abdominal cavity, patients have pain. But wherever one touches the abdomen, there will be severe pain. In the casualty on that fateful night, Wafa, my patient, didn’t have that kind of pain. I was quite confident that I was not dealing with a ruptured ectopic, and relaxed a little bit. Mistake.
Not the diagnosis of the ruptured ectopic. That was right. But where I felt that there was not anything major, the lady had such tremendous pain that she was slowly going into shock. It is true, patients can die of shock brought about by sudden agonising pain, known as Pain shock syndrome…..
(To be continued….)