It was June and for me my early PG days. One day, it was raining cats and dogs, the usual pouring for Mumbai. It was in my first posting as a pediatric resident. We had just started learning to do blood collections and establish IV lines, start saline dextrose drips to babies. We were babies in the department. The complicated cases, the ventilator babies, the difficult syndromes were not our cup of tea.
It was raining very heavily outside. There were no seniors in the hospital ward. We were just running about all over the pediatric ward, from one baby to the other, from one blood collection to the other intravenous line fixation. It was the day of our post emergency ward rounds. All the routine work was to be done like the common household chores.
In the middle of all, a small child about an year old was brought with severe dehydration. He had around twenty vomits and some fifty odd motions. Come, come and go, go. At one moment pulse was felt the other moment it was not. The moment he was brought his heart was still beating, in matter of seconds he just gasped once and didn’t take any further breaths.
I had to be with the child rather than informing the seniors. It was now or never time. I quickly called for two nurses, got the intubation tube (endo-tracheal tube), pulled on the suction machines and suctioned all the secretions out of his mouth, cleared the airway, applied a pillow under his head, held a free flow oxygen tube near his mouth, gave a few cardiac compressions, and then gave him positive pressure ventilation by the ambu bag.
I was not even well versed with resuscitation of children; still without thinking of ‘why’, ‘what’, I did it. But the child was still not breathing so as a last attempt I decided to intubate him. Never had a chance before, only had seen it on dummy and heard of it in lectures and seen it once as a student in the medicine posting in graduation days. But practical on a child, damn difficult!!!
With the gloves on, I removed the tube from the sterile plastic covering, the laryngoscope in the other hand, I got myself seated at the head end of the patient, rather a dead boy, saw what I could. I, with almost no hope, lit laryngoscope light. With the laryngoscope held in the left hand I depressed the tongue and the epiglottis so that I could see two holes: the larynx – the entry to the trachea (air pipe) and the esophagus (the food pipe).The air pipe opening (anterior) and the food pipe opening (posterior). Would I be able to place the tube correctly in the air pipe? I was the dilemma.
But there was no time to think. It was the time when pure action was required. It was like a virgin lover on his first wedding night not knowing as to which hole to go into. Even if the lover failed there would be a next time but here there would be no next time.
I pushed down the endo-tracheal tube, connected it to the ambu bag, removed the laryngoscope and fixed the tube to the angle of the mouth and started ambuing to push oxygen into the lungs. The expansion of the chest revealed that my tube went successfully into the anterior hole. After about eight to ten ambu pushes, with continuing cardiac compression massages we finally heard the first lub-dub on the stethoscope.
By that time a lady senior resident came in shouting on the top of her voice as to why she was not informed. But looking at the resuscitation scene she stood there with a startled look. She took it over from me and continued the C.P.R. (cardiopulmonary resuscitation). By the time, I could establish the intravenous access and push in some intravenous fluids. Then stepped in our pediatric intensive care resident doctors who took over the child and connected the baby to the ventilator. By around fifteen minutes time the baby was shouting loudly as his endotracheal tube was removed out of his mouth.
The child recovered from almost a cardiopulmonary arrest due to grade III dehydration due to acute gastroenteritis. What followed was a shower of praises from seniors because all’s well that ends well. A life saved, the job done.
As time went by, I had revived many babies but that first intubation episode was special just as the first night of the newly wedded lover. The right hole mattered!!!
Well, after such hectic schedules what we really wanted at the end of the day was our hostel. Our hostel bathrooms were cleaned frequently. The toilet had holes all over the door making it breezy. If someone enters without precautionary measures of knocking, he gets to see a public display of private parts. Our bathrooms had been separated by walls. Two had hot water showers which were a luxury sometimes. The separating walls were not full length.
We always thought that there was a gay ENT registrar who had not allowed building the complete wall. Maybe he used to climb on the pipes to have a look at those nude dudes bathing. The girl’s washrooms were different. So we presumed he was gay. Even if it was true who had the time to get bothered.
We were happy that at least we had a good canteen. The taste was very good despite the fact that one may find a fly in the coffee or a cockroach in the Chinese Manchurian running over it. Without a commotion, we always paid the bill and still continued to eat to our heart’s content.
Philosophy was simple, if you get typhoid, T.B., malaria or jaundice you pop up those pills down your throat. It was like a rule, if you are a good resident you had to get one of those diseases. Yes, I had my share of viral hepatitis in my 3rd post, my friend had T.B. and another one had typhoid. A few proxy signatures on the muster were allowed.
Saturday night the cable operator used to put a blue film for the entire male college hostel. Occasionally, female doctors would pop in to damage our liberty. Three years of residency, hostel life was just passing by, how no one knew.
From nine in one room I graduated to two in one room. Here, there was one cot per person and one cupboard to each for books. Pictures of JLO, Kareena Kapoor already adored the walls. Pictures of various Gods and Goddesses were on the book cupboards to give us an extra momentum to pass the exam. There was a so called clothes rack where all undies in various shapes and sizes would hang. Clothes were usually pressed and washed by the dhobi. The senior registrar room was close to the canteen kitchen, though I used to get dabbas from home.
Mumbai has this unique dabbawala system. Hot home food comes to your work place daily by these dabbawalas. Poor mummies think that their babies are chronically starved and require good nutritious food. Today, as a parent I think the same.
I was nearing the end of my third post in pediatric residency and I had got an unusual case of a child born to a commercial sex worker. She was HIV positive. She had taken Zidovudine as a prophylaxis; an anti-retroviral drug which prevents vertical transmission of HIV from the mother to the unborn child.
It was a baby boy born by a cesarean section. Things were alright for about a month but soon the child was admitted for cough, cold and respiratory distress. The x-ray done was suggestive of pneumonia.
Spot HIV-test may give a false positive result as the maternal antibodies can interfere, but in this child’s case we got a positive HIV test both by the spot method and the ELIZA method. Though a repeat test would confirm the HIV status after 6 months, it was almost certain that the child was HIV infected at birth.
It is compulsory in all the Municipal Hospitals to treat HIV patients as normal patients. Doctors are supposed to use universal precautions like face masks, caps, gowns, double gloves, HIV goggles, almost look like a Zombie (green colored) with all this apparel on, sodium hypochlorite solution washed floors which kills HIV virus in blood spillage, clothes and gowns if there is spillage of HIV infected blood. It was a good learning experience, though bad for the patient.
- ‘Someone inside the White Apron’ – a novel by Rajaram Weling will be released very soon
How to treat a HIV infected patient? How to treat a resistant pneumonia because of HIV infection? Also how did the baby get HIV? The mother of the child was a commercial sex worker in Kamathipura area (the red light area) in Mumbai. A Nepali girl forced into prostitution about five years back. She had contracted the disease somewhere in these 5 years by un-protected condom-less sex. She used to serve minimum four to six clients a day. Used to make about six to seven thousand a day in those prime years, but her skin trade decreased as the news of her HIV spread. As the disease groped her, the news of her pregnancy came along. She refused to abort, as she wanted someone to live with.
The AIDS control cell said that because of anti-HIV drugs there were chances of the baby being free of HIV. But that didn’t happen. The baby also had turned to be HIV positive. She did not have much idea about HIV, except that it was a sexually transmitted disease like syphilis, gonorrhea or genital herpes.
But her recurrent cough, colds, fever, vaginal infections, recurrent doctor visits and rejections by her clients made her realize that it was a fatal disease with no cure. The pregnancy somehow sailed through, till the eighth month when she had premature pains and she delivered. The delivery was in the Kamathipura Hospital. The Gynaec hospital situated in the red light area, where there were many HIV infected patients.
Not knowing a lot about HIV, she had only one thing in her mind that she and her baby would be cured of HIV and one day they both would shift back to her village with lots of money which she had earned. Well, when the baby was admitted with us in the neonatal intensive care unit, I was one of the residents for on call duty.
The IV line of the child failed regularly, so every time a new intravenous access had to be found. The child was about a month with us, had his IV lines changed every three to four days, his veins were not at all easy to access. It used to take almost an hour to establish the IV lines. Clean slowly with spirit and betadine. The neocan canula inserted and the needle was withdrawn from inside the canula, blood would trickle out in a stream then only the IV line would be properly in or it would be a failed attempt.
During the first attempt itself I managed to get the intravenous access but as I was sticking the IV line with plaster taper, I accidentally pricked my hand with the needle which I had removed from the same canula, by a catastrophic carelessness.
So it was a prick by a HIV infected needle. Was I to get HIV infection? Was a single needle prick sufficient to get HIV? I was to get married in another 6 months time, will my wife also get HIV? Will she marry a HIV infected doctor? Will my career and life get ruined after HIV infection? Panic struck as I ran across to the students’ welfare committee where I was advised to wash hands immediately with sodium hypochlorite solution and to expel as much blood from the prick site by pressing my finger. Only a few drops came out.
The Zidovudine stock was over. The same medicine was even prescribed to prevent transmission of HIV from the infected needle, which the mother had used in her pregnancy but it didn’t give her any success. It is to be best taken immediately after the needle prick, but I had to wait till the morning till the pharmacy stockist would open and make it available to the store.
All the questions kept on repeating in my mind. The HIV counseling unit in Nair hospital would also open in the morning. A simple prick by a HIV infected needle had disturbed me and rightly so. What was my fault? Someone had unprotected sex with someone who had HIV infection and now I was the one to be HIV positive.
- Dr Rajaram Weling
I just broke down into tears. My parents just came over to the hospital to console me and give some words of hope. Doctors who work with HIV patients are at constant risk of getting infected, one of the many aspects of HIV. Next morning it was a different situation. Zidovudine popped up, the department bosses at the HIV counsellor’s cell. HIV tests were summoned. P.C.R. test was done. I was on Zidovudine prophylaxis almost for 3 months. I used to get nauseated by the medicines but there was no alternative.
Three reports for HIV done over six months. All turned out to be negative. I was finally HIV negative. HIV does try relationships and patience. Doctors, patients, relatives, husbands, wives, spouses, children, neighbors and the stigma of getting HIV infected.
The mother apologized to me when she came to know of the episode. I consoled her that there was no such need to be sorry to me. I just patted her back for the sadness and the bitterness which the world would have against her fatherless child.
The child went home from the hospital after being treated for the infection. Having almost stepped into the shoes of a HIV positive patient was an experience which I laugh at, thinking today.
About the Author:
Mumbai based Dr Rajaram Weling is a Consultant children specialist, MD Pediatrics, FCPS Mumbai, DNB Pediatrics. He did his MBBS and post graduation in pediatrics from Nair medical college, Mumbai. According to him learning never stops, the day a man stops learning he is dead.
The above incidences are part of his debut novel ‘Someone Inside The White Apron’ which is ready for release.
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