I rush to the emergency to find a crowd standing next to a cubicle which houses a critical patient. A mob stands outside the hospital; friends, relatives, strangers. All ready to pounce on any unsuspecting medico who does all he can to help the patient.
The patient heaves and gasps for breath as the bandage on his head soaks with blood. A person is not oriented or conscious will need to be intubated in order to make sure that he does not have problems breathing. It needs to be done so that oxygen reaches his lungs and brain. So that his senses don’t get affected.
I reach the head of the patient to intubate him. Intubating him will need the patient to be sedated and unmoving. Intubation is the procedure by which you introduce a plastic tube into the patient’s windpipe.
That being done, he continues to pour out blood through his mouth.
RTA (road traffic accident) with head injury where the CT Brain shows Sub-Dural Hemorrhage, Sub-Arachnoid Hemorrhage and fracture of the Base of the Skull. The patient also has a femur fracture. One femur fracture can cause the loss of about One and a half litres of blood. Now this, coupled with Brain injury can cause altered blood flow to vital organs.
In short, it is a medical catastrophe if not treated at the earliest.
Meanwhile, the crowd outside swells. There are muggers, ruffians and there are drunks who aren’t ready to listen to anything the doctor says, let alone understand the patient’s condition.
Curious faces, peep and frown. A patient’s attender starts shouting claiming not enough care is being given.
I send the rest of the crowd outside and ask for someone who’s responsible for the patient to stay inside.
One person stays inside.
I explain to the patient’s attender that the condition of the patient is serious. That the treatment given here is the maximum possible that can be given. That even if the patient is taken to another hospital, the same prognosis will be explained to them.
I explain to him the risks that accompany the patient while carrying the patient in the ambulance.
The ambulance could meet with an accident. The constant movement could alter the hemodynamics of the patient. That the similar care that is given in the ICU cannot be given in the moving vehicle. That there is only limited oxygen supply and that the patient can be taken to only one hospital.
“Have you understood all the risks that can happen while taking the patient 70km to Bangalore?”
“Yes,” he says.
“Have you agreed for the same?”
“Yes”, he says. Adamant.
“Have you booked an ICU bed in the other hospital? Because most hospitals are full, and you will have to inform them beforehand if you want to admit a patient in the hospital.” I tell him.
He looks clueless.
I let my colleague know the status. And we quickly try and arrange a bed for the patient in the hospital in Bangalore.
And he signs on the sheet that I give him. The only piece of paper that will save us from trouble. It costs 7,000 to shift a patient to Bangalore. And no, us docs don’t get one rupee from it.
Incidentally, 7,000 is the amount we get per a month as stipend.
Meanwhile, it’s getting colder outside. The crowd is getting more and more agitated with every minute that passes by. I ask my colleague and nurse to get all that’s necessary to make the trip. Medicines, injections, fluids. We shift the patient into the trolley and shift the patient inside the ambulance.
I connect the patient on to the ventilator. The patient’s attender asks if he can sit beside us. I say no. There isn’t place enough for another person and it’d be hard to do work with the constant interference of the relative. My colleague asks him to sit in front.
“Go Go!”, the Casualty Medical Officer motions us. Wishing to wash his hands off the matter at the earliest.
And then we leave.
Outside the service road is dark. It’s 11PM. Lone cars and lorries speed past. We get on to the highway and speed past.
Up the blue lights scream for space on the road. My hand’s on the patient’s pulse and my eyes are transfixed on the monitors. Looking for any signs of the patient slipping into the netherworld.
The ambulance swings from side to side on the highway. The nurse, a brother, wipes the blood oozing out of the patient’s nostrils and mouth. It’s a basilar skull fracture. Our friends from the ENT department have done all they can to achieve hemostasis, but the patient would need operative intervention.
My colleague, a surgery resident quickly falls asleep. My head feels woozy, with the constant pendulous motion of the ambulance. I suddenly feel the pulse of the patient slipping and the heart rate increasing. Bad signs I think to myself. I quickly intervene by giving injections and appropriate intravenous fluids.
The patient’s stabilized. For now.
It’s almost halfway now. The patient is sedated and is in a deep sleep. He needs to be so in order to cope with the stress of travel. But his senses are still intact. He begins vomiting and the sheets begin to get wet.
The male nurse and I quickly reposition the patient to avoid further complications.
The surgical resident wakes up while the ambulance crosses half the distance to Bangalore.
“Dude, I feel like vomiting,” he tells me. Little knowing that I feel the same too.
It’s unlikely that we feel anything else. A closed space with no ventilation and the patient’s body fluids pouring out while the air in the ambulance feels mal-odorous.
I ask the brother to give him a tray so the resident can relieve himself. And some water.
We move slower as we reach closer. It’s the Bangalore traffic and midnight. And it hasn’t changed. And I wonder where people would go at that hour. The ambulance swerves and swings through the cars and buses.
We huddle in the back while the driver moves at 50 kmph on the opposite side of the road.
Our hearts are in our mouths.
But it wouldn’t make a difference. We all will die someday anyway. I doubt the timing would make any difference to our lives. We were in hell anyway.
We get past the bigger roads and move to the arterial ones. We get to the road that takes us to the hospital. My hands firm on the patient’s pulse. With all the movement and disturbances, the monitors cannot be trusted.
We reach the hospital and the driver moves the vehicle to the casualty department. The ambulance stops much to our relief and the driver gets off.
He opens the door after an hour and a half and I’m exposed to the biting cold.
Curious people and hospital staff peep into the vehicle. Trying to gauge what we’d brought to their hospital. I ask the nurses to get me an oxygen trolley and an AMBU bag. We shift the patient outside and take him into the casualty.
My hands are constantly inflating and deflating the bag that supplies oxygen to the patient’s lungs. Something that needs to be done. Every minute.
My colleague, the surgical resident, asks for the consultant on duty and explains the condition of the patient to him. I hand over the patient to the hospital staff and nurses and get back into the open.
My colleague and I stand outside relishing the Bangalore air. Thecity’s calm.
Quiet. Cold. Still.
The driver and brother walk back from the hospital. The brother holding the sheets and equipment from our hospital. Our hospital is poor. The nurses cannot afford to leave anything behind.
We get tea and something to eat and then head back.
We are bundled back into the ambulance. I collapse on the stretcher. Two hours of sleep the day before and I will steal any rest I can get. We head back to our hospital now.
It’s pushing 1 AM.
At the back of my mind, I wonder how my seniors have gone through the same sh*t that we’re going through. And I wonder how they got past it.
When the going gets tough, the tough get going.
The journey back is uneventful. Apart from trying hard to get snatches of sleep in a prison-like environment.
We reach at 2:30AM. I get out of the vehicle. Head woozy. Legs unsteady. And head back to my hostel room. I say bye to my colleague.
I crash on to my bed after a wash. And look for any messages or calls that I may have missed with all the mayhem.
15 minutes into sleep and I am woken by another call.
“Hello Doctor, this is the Casualty Medical Officer calling. There’s a patient with Diabetes, Hypertension and Stroke in the casualty. The ICU is full. The patient is intubated….”
I get up to make another trip. Again.
About the author: Sharath Krishnaswami is an emergency medicine physician and an anesthesiologist. The experience that occurred above happened during his residency. He is best described as someone who likes poetry, theater and travel!