Date: 9th June 2014, Time: 1.30AM, Place:
PICU II, Fortis Escorts Heart Institute, New Delhi.
It just occurred to my lazy brain that it has been exactly
10 years since I started working as a salaried professional. Nine years of Pediatric
Intensive care!! But then working in pediatrics started a year earlier, as an
intern making it 10 years of Pediatrics. These 11 years had the good, bad and
the ugly at the five different hospitals I had/have been as a student and as an
employee. Not sure it is a wise idea to write a review, but who cares? I rarely
get wise ideas.
Entry into the Pediatric Intensive Care
After completing rotational posting in various
departments, it was amply clear that a few departments weren’t to my liking and
I wasn’t to the liking of certain departments/its doctors. Not that I was that
bad, it was just they “preferred” others. The message was loud and clear at
some stage. Fortunately the doctors in the Pediatric department were willing to
accommodate me in the Pediatric ICU (PICU). Traditionally PICU wasn’t most
sought by the aspiring interns and I took it easy as I approached the “Panel
interview”. The evening before the panel interview, I was in for a shock when I
learnt that six of us were competing to get into PICU. Thankfully five of us
were selected for PICU and for the first time I valued it more than before.
The Beginning
I began my internship with a night duty (the very
first day/night as intern) alongside a senior – a typical bossy rude lady. The
very first instructions I got from her was that I should be staying awake all
night, be inside the unit at least 5 minutes earlier ,round the patients every
hour and not do anything to spoil the cadre’s reputation. In the next half
hour, she dozed off only to be woken by me at 5.30AM. I religiously followed
her instructions only to see the nursing staff laughing at me doing everything
so sincerely. I was worried if this would become my routine for ever. Staying
up all night was tough but I had no choice. Fortunately for me, I had to do
only three nights. The subsequent two nights too passed without noteworthy
events except that I had learnt to occupy myself with the “Manual of Pediatric
Intensive Care by Chang”.
Within the next few days, we interns in the PICU
were forced to read a lot, were told to find a list of topics for our semester thesis
and were told to actively participate in the weekly pediatric cath meetings.
That was too much of work and I hated it. I don’t think that mattered to
anyone. The problem in reading a lot is one becomes a little eager to implement
things in reality. Suddenly rounds and patient examination in the unit had got
interesting - I could sense and
understand a lot of things – ECG, CVP and arterial waveforms, sounds, the
numbers on the monitors!!. Looking back, that was probably the beginning of
what led to the transformation of a student becoming an intensivist.
The Transformation
A few days later, on a Sunday when the staff in the
hospital would generally be minimal, one of the kids in the ICU got worse. The
duty anaesthetist was present in the bedside along with me. Being a junior, she
didn’t want to take the “massive decision” of putting the child back on
ventilator and was in dilemma. Sensing this I insisted we put the child on
ventilator, which meant I would get a chance to perform a intubation. She was
convinced, but much to my disappointment called a senior who did the
intubation. The first challenge I ever faced was no more mine. Nearly 2 weeks
in the PICU and I were yet to do “something” in the unit. As luck would have
it, my chance of becoming an intensivist and facing a challenge arrived in a
couple of days.
It was another set of night duties – again with the
same senior. I began my work on time without waiting for time, as she always
entered the unit atleast 20-30 minutes late. That particular night there was no
sight of her even at 9PM. slowly one of the colleagues told me that she would
not come if she didn’t by her standard time. I was relieved!! But the prospect
of handling 4-5 critical children without a senior’s support made me nervous. There
was a surgeon and an anaesthetist on duty- so all I had to do was pick the
problems earlier and call for their help. That was a little comforting. What I
learnt in the next few hours was to trust myself than others – whomsoever it may
be. Even today, I consider that particular night as the one which changed my
approach to emergencies.
Sometime post midnight, the child whom we had put on
verntilator a couple of days earlier deteriorated. I knew the cause and much to
my own surprise the treatment. As an intern, I had no rights to do anything on
my own. The phone call to the Doctors lounge went unanswered and the ward boy
who went to call the doctor returned alone. In order to explain the gravity of
the situation I reached the lounge, explained the situation. The reply I got shook
me to the core; 11 years later I still shake my head in disbelief that he
actually said that to me. It saddens me that the moron is still practicing somewhere
in this world, and living amidst passionate and committed medical
professionals. Here is how the conversation went on between us.
Me: Excuse me sir... blah...Blah...blah... (Patient
details, status... etc...)
Dr.Moron: hmmmm... Why are you telling me all this??
I am not a pediatric surgeon... Go and call those pediatric surgeons sleeping
at home.
Me: BP is going down fast
Dr.Moron: so????? Do whatever you want...
Me: blank….
God bless him
with some sense!!
I did what was supposed to but it was not helping
the kid. If I were the call the Surgeon who operated upon that kid, it had to
be the legendary Dr K.M.Cherian at that time of the night. Not to mention I was
trembling in fear. The next option was the assistant surgeon in the case –who would
probably not give any worthy inputs. With a bit of hesitation, I rang up
Dr.Robert Coelho, who was mentoring us.
Me: Sir... blah...blah...
Dr RC: hmmm...
Me: Still bad…
Dr.RC: hmmm
Me: Hemodynamics not holding...
Dr. RC: hmmmm
Me: Is there anything else that I can do, sir..??
Dr.RC: (pause...) hmmmm...give 40 milligram of
Hydrocortisone... Okay????
Me: yes sir...
As we were
hopelessly watching the monitor, Dr.RC had arrived in complete formals, wearing
the green STAFF gown). Whatever may the situation and he would still find time
to wash his hands before entering the unit, a practice I still try to emulate. It
was amply clear that the child would survive for another few days at the most.
As Dr RC left the unit, I walked along with him and told him about the cold
response I received from Dr. Moron. To this he replied “call me anytime of the
day, I will be here for help. Keep doing good work”. That was the first major
appreciation I ever received in this eleven years. From then 24 hours in a day seemed less. Theory,
journals, research papers, medical records, cath meets, project review meetings
all happened in a day and I still found some time to sleep and work all night. Life appeared very interesting. Without realizing I probably read more than what
I did in the preceding three years. Certainly one of the most productive phases
in my life.
The first step in the decade long journey
Towards the end of internship I had made up mind to
move out of MMM and much to my liking I found another wonder place in Narayana
Hrudayalaya, Bangalore in the department of my choice – Pediatric Intensive
Care unit. It was a Wednesday - June 9th 2004 - the first day for me
as a salaried professional. The sequences of the events are still afresh in my
memory – right from the minute I joined the unit for morning rounds. Dr.
Raghunath, Dr.Rajesh Hegde, and Dr. Harsha made me feel at ease. I was given
minor tasks/duties which were more than what I had expected. A pretty smooth
first day and a memorable one too –for a wrong reason. Dr.Rajesh introduced me to
Dr. Frustrated, someone who must have been in his late 40s and moved away. The
very first conversation between us went like this.
Me: Hello sir... Blah blah blah...
Dr. Frustrated: (laughing sarcastically)… We peoples
are working in this field for nearly 15 -20 years and we ourselves are not able
to manage things... Do you think you are an expert after working in a PICU for a
year?
Me: (Shocked)...
Dr. Harsha: Bidee saar... he has just joined...Arun...Come
lets go to the wards for rounds... Don’t take him seriously... (I still wonder
how he sensed I was upset)
It was a few days later that I got to work with Dr. Rajesh
Samuel, someone with whom I did the most
number duties in the subsequent 18 months. He was probably the first person who
made realize that fun and work can co exist easily. Working in NH was loads and
loads of fun. I enjoyed the responsibilities given to me. The best part of the
job was transporting sick children by ambulance in city traffic and to/fro
other hospitals. I was working with some legendary names in the field of
Cardiac surgery – Dr. Devi Shetty, Dr.Rajesh Sharma, Dr. Colin John, Dr Ashley
and others. It helped having a lot of younger people of similar age and experience
in all the departments – ICU, physiotherapy, perfusion, anesthesia and nursing.
The atmosphere was always festive and almost all the doctors were very young at
heart. It was in NH that I got to meet some of the nicest people in the field
of medicine – Jamuna, Dr. Agnis, Dr. Prassanna, Dr.Naveen, Dr.Ramanathan, Dr.Harish,
Dr. BenedictRaj.Dr. Amit Mhatre, Dr. Vinit Samdhani, Dr. Senthil Ganesh...the
list goes on... The only times there was gloom were on Monday mornings when the
ICU team was torn apart by the surgeons in the weekly meeting. It demoralized
me at times that my boss, Dr Cajetan Tellis and Dr. Frustrated always found
soft targets in me and few others when they were taken to task by the Surgeons
in the meeting. But it was ok, as long as they realized my value to the team.
Dr. Frustrated was very tough to handle – was getting
worse beyond a point. Just a sample – One Sunday on duty, he came to know of my
plantar fasciitis through someone and enquired me about it. And he made sure I
never sat even for 5 minutes till Monday morning. All this came to an end when
I yelled at him in the middle of ICU – something I regretted years later!! May
be I could have spared him...Poor old man!!
A year without Pediatrics
Leaving NH was a tough decision and a well thought
one. I left NH in the pursuit of better future which I am yet to find!! As a
stop gap arrangement joined Dr. Kamakshi Memorial Hospital, where my heart was
never there. Though I put my best efforts, they never transformed into results.
It didn’t help that the chief anaesthetist there had very little faith in me
and I was not working with kids. Nevertheless, the experience wasn’t bad
either. In less than a year I was ready to move to another job – back to
pediatrics where my heart was.
Disastrous Decision
My mentor offered me a job when I had made up my
mind to go back to NH. Working with mentor, setting up a new unit charged me up
and I thought I was ready for the task. MIOT hospital wasn’t particularly popular
for being employee friendly, and I was cautioned by a lot of well wishers
including the medical superintendent of KMH. little did I know that my primary problem
would not be the employers but my own team members. Setting up an ICU is itself
an experience and I thoroughly enjoyed every bit of it. I was determined to be
part developing a pediatric unit come what may. With a group of committed and
passionate people, it should not have been any difficult. But what I found in
the next one year was that the group was made up of disconnected and self centered
individuals, who probably entered the project assuming it would be a bed of
roses or probably wanted to be opportunistic.
Our first official surgery was done on March 9th,
2007 and I was told to work in night as there were others to cover up in the
day. The same logic was given for the subsequent nights by one or the other
doctor in the team and till April 8th 2007, I worked only in nights.
That was the longest stretch I had ever worked without break! That record was
broken immediately when I worked 44 nights without break from 9th
April 2007 to 22nd May 2007. It was not easy; but I thought we were
building up a unit and was under impression that I was helping my colleagues. I
was required the unit was busy, I had to man the unit on Sundays when other
doctors could stay home, had to do nights when only junior nursing staff were
available for nights!. Another cycle of nonstop night duties went on from 28th
May 2007 to 28th July 2007!!!
By August 2007, I had a colleague who could shares
duties with me and with that I had to do night duties only half the month. Life
was getting easier. But the ever complaining colleagues never seemed to change.
I was proud of the work we were doing and the results were great. Sometime
around the year end and early 2008, the frustration among some of the
colleagues reached higher levels. Call it frustration or lacks of commitment,
each of them appeared to work in different direction letting the primary
objective – patient care affected!! I would have been very happy had any of
them had taken the leadership when there was need and guided the rest of the
team. Instead each of them passed the buck to one another. Surely, the
commitment was down. I saw things spiraling down in day today basis.
It was easily the worst phase in this decade long
career. Those two months have left such a scar in my memory. Six years after
all that have happened, I still feel, my colleagues then should have worked as
a team rather than letting their personal ego takeover the demanding
situations. In case any of them are reading this, here are those events which
still hurt me. And gentlemen.. DON’T DARE TO BRUSH THIS ASIDE.. THIS IS TRUTH
AND JUST TRUTH!!!!
Event 1: A neonate post ASO was struck on ventilator
due to sepsis and respiratory failure. One night, when we had trouble ventilating
the child, I requested one of my so called heartless superior to rush to the
hospital for opinion, He instead chose to stay back and suggested I don’t call
him till morning...
Dear Doc... You often critised the surgeons when they had
issues with ET tube size and its placement. Am not sure if you will be ashamed
to know that finally the job was done on my request by a Cardiologist!! Yes we
did lose some valuable time and also that poor little kid.
Event 2: Around 9PM, a 4-5 month old kid post ASO
with multiple VSD closure was shifted to ICU. After routine auscultation I
suggested there was a right lung atelectasis and a saturation of 90% was to be
taken seriously. The surgeon and anaesthetist ignored and right in front of all
of us, the kid crashed. Then again I remember telling the surgeon not to open the
chest as we would be better off with external CPR. But then surgeon’s ego didn’t
let him to that. Instead he went ahead with his plans only realize later that
external CPR would have been better.
Event 3: A 2 year old kid who underwent RV – PA conduit
change, was ventilated overnight, much against the wishes of one of the
anesthetists. After my night duty, I remember telling him in particular that
the child had signs of reperfusion injury and to wait for extubation. Instead
he chose to do it in his style and the result was disastrous.
Event 4: Extubating a 2 year old post ASO kid in the
presence of pneumothorax!!!
Dear Dr Anesthetist, You dont need to do fast track
extubations just to prove a point to your superior! I only hope that you
dropped this practice in MIOT itself.
In a span of
40 days, we had lost 6 children, out of which I thought we could done better in
atleast 4 of them. I felt helpless and when I could not take it anymore, I
resigned explaining the problems to my mentor. I was really glad he chose to
relieve me knowing he could not make life better for me any further.Looking back, I am thankful to all those there in MIOT who made me mentally stronger, I can now set an unit all by myself and even run it successfully!!! It would have been better had I not made the worst decision of my career in moving there.
6 years and on...
Relocated to Fortis Escorts heart Institute, New
Delhi in 2008 with a lot of expectations and additional role of a research co
ordinator. Six years later am still searching for the research co ordinator job
I was promised. LOL!!! Oh yes I was “about to be” a Critical Care Co ordinator,
an ICU manager, an ACLS instructor and even PA course co ordinator!! Unlike the
research co ordinator, the rest of the positions are very much there - just
that I continue to be what I was a decade earlier. I write scientific articles,
participate in academic meetings, do every task given to me with the same
enthusiasm I had a decade earlier but the truth is that all these can take me
only till where I am. Easily the best place I have ever worked in and probably
the most passionate and tolerant people.
Verdict
A decade later, I still consider myself a misfit in
this profession looking at people whom I work with. At the same time I do not
know the profession in which I would fit in naturally... An all India truck
driver possibly!!
