Here’s what happens at a casualty ward. Read this before you justify your anger against doctors
Never — in my 365 days of internship— was my bodily safety the focus of my day.
For any young doctor, their first casualty posting is scary. Being a casualty intern means that you are the first doctor that patients requiring immediate treatment will meet.
You worry endlessly: what if the condition of the next patient is too serious? What if I am not able to work fast enough? What if we have to resuscitate — and what if it doesn't work?
What if the patient is too drunk and I am not able to get him to sit still to get the mandated blood draw?
What if it takes too long for an MI patient to get the ECG?
What if I am not able to administer iv medication to a seizing child?
What if a very sick baby comes in and we have to tell the family that all the ventilators are already being used? What if the patient’s family refuses life-saving treatment?
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A few days into the routine of casualty — you realise that there are checks and balances in place.
If you are struggling, then there is a senior doctor immediately — the junior resident (JR) or the Casualty Medical Officer (CMO) who steps in.
A more experienced hand will take over if they see an intern not working fast enough. The nursing staff will have the medicines prepped and ready even as the child is brought convulsing through the double doors. JRs will spot the belligerent drunk and engage him in conversation if you are nervous, and ensure that his investigations are sent out with a minimum of fuss in a timely fashion.
Each time somebody walks in asking for a ventilator, someone will call the ICU, on the outside chance that one has been freed up in the last five minutes. The Senior Resident (SR) on duty will explain the family multiple times that their child won’t get a life-saving ventilator at this hospital. An anesthesiology specialist will be posted to help resuscitate a patient who urgently needs an airway placed to allow him to breathe. Surgery, medicine and pediatric teams are on standby simultaneously for all patients who need in-hospital care — be it an emergency appendicectomy or admission for management of a stroke or a heart attack.
A week in casualty — you realise that your litany of worried ‘what-if’s can be truncated. At best, casualty runs like a well-oiled machine with each patient attended to within minutes and given the optimal care. As with any machine with multiple moving parts, there are days when one has to work in less than ideal conditions. The casualty ward may be short-staffed, equipment may not be working and certain medicines may be out of stock or ‘NA’. Particularly at these times, the doctors rally around and, with the spirit of jugaad and the Hippocratic oath, ensure that the patient remains the primary focus. The team follows principles of triage and ensures that time-sensitive treatment is administered first, followed by less urgent interventions, and so on — until each patient is made comfortable.
Yes, you find your yelling voice. You yell at the attendants of patients who crowd around and block access to the patient. You yell when you need to cut through the panic and the decibel levels in the casualty to convince a reluctant family that their dear one needs life-saving surgery. You yell at patients when they are in the casualty section just to avoid the long queues at the OPD. And you yell (rarely) at the theatrical patient who is taking up valuable time that other patients ought to be receiving.
The doctor walks in — for a long 12-hour, sometimes an 18-hour shift — into the busiest part of the hospital. (We are talking about 50 patients being walked or wheeled in within 15 minutes into a room of the size of two tennis courts with only 15 beds lining the periphery, and stretchers and trolleys arranged bar to bar in the rest of the space)
The doctor knows that anything from a bee sting to kerosene poisoning can be brought in through those double doors — and it is upon the casualty team to separate the urgent from the emergent.
She yells at the patients and their attendants — not because they stepped on her toes, or called her a sister, or jabbed into her mid-section with an elbow, or hurled a slurring string of abuse at her — she yells only when they interfere with the treatment, be it their own patient or a patient in the adjoining gurney.
It’s only in the wee hours of the morning, around 4 AM— when all the patients are stable and have comfortably dozed off, and the early morning rush hasn’t descended upon the hospital yet, that the casualty team catches a breather.
Over chai and Maggi or masala chips, they swap battle stories and congratulate each other on having arrived at the holy grail of a quiet casualty, if only for an hour.
Do you see a theme here?
The focus of this young intern is entirely the patient.
The minute she dons her coat and stethoscope, all she is thinking about being prepped and ready for the patients that will require her care through the shift. Let today be the day when we can tell a family that we have a ventilator available. And in her heart, the intern is muttering — Please, please! Don't let any patient die on my watch; Please, don't even let someone bring in a ‘brought dead’ patient. Yes, patients die in the hospital. But let it not happen in this casualty. Not today.
Never — in my 365 days of internship— was my bodily safety the focus of my day.
Not once did I worry about losing an eye while at work, or about being pelted with stones that would land me in the ICU with a fractured skull.
I am sure the interns at NRSMCH, Kolkata, who walked into their shift on June 11, 2019, were not worrying about anything other than the patients they were going to see. Yet here we are — the doctors in casualty were attacked because a 75-year-old patient (some reports say the patient was 85) died on their watch. The details of what followed differ from report to report — the attendants thought the injection administered caused the patient’s condition to deteriorate, or they were upset because they were yelled at, or that the body wasn’t released expediently.
A matter that could have been raised in a formal grievance process devolved into a mob of people storming the casualty ward to attack the duty doctors. The intern is in the ICU after having undergone a craniotomy to raise the portion of his skull that sunk into the substance of his brain as a result of the assault, the other doctor has been discharged after having been treated for various injuries.
Unfortunately, this is not an isolated incident. Last year, there have been over 50 instances of mob violence against doctors. It is usually the young doctors who man the casualty and who are at the receiving end. These attacks have not been picked up by media — reports circulating as first-hand Whatsapp accounts and disturbing videos in medico circles. What is worse is that there has not been even a single conviction.
Doctors have protested by going on a strike — and by force of habit and the ethos of their profession — they worry about their patients while on strike. Patients already admitted are of course looked after — but also we hesitate to close the emergency departments. Our protest — to the public, the administration and the media — is restricted to the out-patient department.
In Dr RML Hospital, senior doctors have offered to discharge the duties of the striking junior doctors during the three-day strike so that the patients don’t suffer.
Instead of a platform and solidarity, the strike earns us derision and ire, and currently in West Bengal, more violence. The public there is retaliating at striking doctors with mob violence targeted at medical student hostels, doctors’ residences and vehicles.
Unsurprisingly, the worst of the threats are towards the female doctors — of rape and acid attacks. Fear of being raped is an active worry for most women.
Never — in my 6.5 years of having been a doctor-in-training — have I been worried that I would be raped because I decided to pick the “noble” profession.
The patient — my patient — has been the focus of all my worries. And that is what my professors and mentors all say will make a good doctor. Diluting this worry and concern with worry for my safety, and a growing sense that it is crowd management and optics that matter, will make me a tenth of the doctor that I am.
Extend this to all the young doctors, presently living through the violence, worrying about friends and classmates trapped in these hostels.
Compound this worry with an active antipathy towards ‘them’ — the patients and their attendants that will turn upon us just because we tried — and you have a complete bidirectional breakdown of the doctor-patient relationship.
Also add to the ranks of disillusioned young doctors, young doctors in training who will leave this country to practise elsewhere, and the students poring over their biology textbooks who will decide for their career “anything but medicine”.
We are at a turning point — without active remediation we are going to launch into healthcare crisis that might take decades, if not centuries, to fix.
And you, fellow citizens, are the ones who will suffer.
Your apathy towards your doctors will ensure that you have crippled the very hands that can heal the disease that is gripping our collective psyche.
Save the doctors. Save yourself.