therantingdr

[therantingdr]

34.

The Kid (Part 3)

Anyway, with the help of the book I downloaded, we intubated the kid. To everyone’s surprise his saturation was 100% when he was on ambu, but after intubating it wasn’t going above 79. I was a 100% sure that it was a tracheal intubation, and not an esophaheal one. So i guess it either was wrong reading while we were doing the ambu or it’s wrong now, or we put too much pressure and literally burst his lung to cause a pneumothorax, or we pushed the tube too deep that only one lung was being ventilated. Idk. I ruled out esophaheal intubation, and pneumothorax cuz air entry was present bilaterally and good tidal volume was being generated. Couldnt hear the breath sounds well tho since the hospital thinks it’s a good idea to keep cheap adult stethoscopes in the ICU. I also remember holding the tube at 14cm while the nurses fixed it to his face. So we ruled out the possibility of the tube being in too deep. So I assumed that the reading was wrong when he was on ambu as it’s rare for a patient to easily maintain saturation especially when he is lying flat and has pulmonary edema. So I decided to wait for a while and hoped the saturation would improve. It made sense then. But to my dismay, nothing improved even after half an hour of ventilation. My gut told me something’s off with the tube, so I decided to start from the basics and check the position of the tube. There it was. It was fixed at 16cms, and not 14. Maybe it moved while they were moving him post intubation. Idk. This wasn’t the time to think of how it happened. So we pulled the tube and fixed it back again at 14cms and we could see the saturations improve right away. Such a relief it was. Got the CT done. Normal. But then why did he go unresponsive? The next thought was hypoxic injury. We were to give him NIV support but we didn’t have a suitable mask that fit the kid. And a while after getting the CT done he started waking up, meaning it actually was hypoxic injury. When I called the nephrologist, who was also the primary consultant to inform what had happened, and that the kid is awake now, he told me to extubate the kid. I said “yes sir” and cut the call. Tbh I had no intentions to extubate him. Cuz first of all, he hadn’t even seen the patient yet. Second, he still had crepts in his chest meaning he still had pulmonary edema. Third, we didnt have time to wean him off yet. Fourth, if he has pulmonary edema, and is in distress after extubating, are you telling me that a face mask of the right size for NIV will magically appear in this shithole? It was way too risky. Thankfully I didn’t have to answer to the consultant as the family (calmer now) told me they want to take the kid elsewhere.

I couldn’t have been more relieved as only I and the nurses knew the difficulties we had to go thru to keep the kid alive despite being in an inequipped hospital. They know the ICU isn’t capable of handling such a case. It’s not a secret. They didn’t even have intravenous paracetamol for kids. Even the head of the ICU, the intensivist was shocked that they had admitted such a small kid. And even if they did, they didn’t admit him under a pediatrician (the newly appointed pediatric cardiologist). Instead they admitted him under a nephrologist just cuz he had high creatinine levels and metabolic acidosis. We didnt even know if it was CKD. It easily could have been AKI. Sure the nephrologist we have is a good and experienced doctor. But I wondered how many pediatric patients has he seen? 50? 100? Definitely not more than that. If it was AKI, then we need to treat the underlying cause that precipitated the AKI, and for that who’s better than a pediatrician?

I met 5-6 of the family members after my duty, while I was exiting the hospital. They told me that they were too poor to continue the kid’s care in a private hospital. I guess that time I could be more of a human and less of a doctor. I could sympathise more with them. They were planning to take him to another hospital nearby. Another shitty one. Although it was a personal opinion, I had to tell them that it wasn’t a good idea. The next hospital was farther away. I told him honestly that I didn’t know if the kid will make it that far but if they had financial issues and if they wanted to give him the best chance, they had to take the risk. But somehow I had hope. That he’ll make it. Otherwise I wouldn’t have suggested it. But for obvious reasons, I couldn’t tell them that the kid will make it for sure.

Anyway, we did the best we could as a team, and am happy with how we handled things. But I still kind of feel the regret for hoping the kid to be admitted just to prove myself tho at the risk of his life. Of course I didn’t go “I don’t care if he dies, I just want to prove myself”. But still…Makes me question the type of person I am. Like what defines a human? The first thought that comes to his mind, or what he rectifies it to and how he acts after that? Isn’t the person truly ‘good’ if he doesn’t get such thoughts in the first place? And just like most thoughts in my head, the conclusion to this one too is ‘I don’t know’.

P.S This is my coworker who “helped” me throughout the chaos. From 5pm onwards we had 8 procedures and 3 intubations. But he decided that taking the 3 admissions was enough and decided to take a good 6 hour ‘nap’, while I worked my ass off even for the admissions he had taken.

[therantingdr]

33.

The Kid (Part 2)

The consequences and guilt of killing a kid just cuz I had the audacity to try it in the neck were unimaginable. Especially when I was a hundred percent sure no one would stand by me if shit went sideways. Neither the nephrologist, nor the intensivist. Praying to the Gods who for the record, a while back had decided to shit on my peaceful time, to not fuck it up, I hesitantly went ahead and put the line and thankfully it all went perfectly. As perfect as one could be done. Everyone around were calm (at least on the outside), everything in place, and the procedure in itself was smooth af. All I had in mind was to not go thru the vein and hit the artery. Lowered the angle a bit as soon as I hit the vein so the sharp end of the needle isn’t pointing toward the other wall of the vein as the vein was collapsing with each breath the kid took. Secured the needle with 4 fingers right after that so it doesn’t go any deeper. Was all that skilful? Sure. But I’d never claim that it was all my skills as I honestly believe a big chunk of it was pure luck. Especially given the number and enormity of things that could go wrong. Anyway, dialysis was started and we noticed immediate improvement in the kid. We all were relieved that we somehow got through the difficult phase. To no ones surprise, we soon realised we didn’t.

It was a 2.5 hours dialysis session, and after about 2 hours we noticed the kid was unresponsive, pupils blown. Both unresponsive to light. Fixed and dilated. He had a pulse. The monitor shower a heart rate of 68. Now the first thought that comes to our mind in such a situation is intracranial hemorrhage. The kid had this vacant look in his eyes, had his teeth clenched. Was he having a seizure? I couldn’t tell. Nearly shit my pants. Cuz imagine trying to cure someone and instead making it worse, and that too, a kid. The thought of having to explain that to his parents was daunting. Somehow I snapped out of it, and called in the other doctor for help and started shouting orders while we sprung into action. Before performing a CT scan, we had to secure his airway. I’ve never even properly seen a pediatric ET tube, let alone use one. Thankfully we had one in stock. I started preparing for intubation, while the other doktok informed the family about the worsening situation. Idk which one of the two was more difficult. Anyway, he came back while I was still intubating. And to my surprise he told me that the mother is going bullocks, saying her kid was all fine before she brought him here, and was antagonising the people around, and that shit may get hostile. And I couldn’t hide my reaction to that as I went “Are you joking!?” Cuz the fuck you mean he was alright before he came here!? He has been sick for 2 years, had breathing difficulty since 2 weeks while you kept him at home waiting for him to be magically cured, and was referred from the previous hospital when they couldn’t manage shit. So yea, what the actual fuck do you mean “he was fine before we brought him here!?” Sure, she’s a mother, and it’s a normal human reaction to try and shift the blame on others when guilt takes over, but ffs say shit thats at least believable…

vp.

[therantingdr]

32.

The Kid (Part 1)

Back again after a long time, and what better way to start off by another guilt-filled story with some ranting?

It was one of the Saturday duties I’m usually on. And I expect them to be calmer than other days since it’s a Saturday. No proper reason behind it as the OPDs still work and no consultants are usually on leave, emergencies work just like any other day of the week. But just cuz it’s a weekend, I expect Saturdays to be easygoing. Anyway, it was actually easygoing…till like 5pm.

At around 2:30ish, while coming back from lunch I saw a small kid in the ambulance outside emergency, crying and on oxygen support. Maybe it was out of my past experiences and the newly joined pediatric cardiologist, my first thought was kid’s got a hole in his heart. The manager on duty informed me that the kid’s up for MICU admission. My mind went “this is your time to shine, cuz you know how to manage kids with holes in their heart”. For some reason, even after all this time in the ICU, I still feel the need to prove myself to my consultant. But yea, even before I finished that thought, he further informed me that his creatinine levels were high and may need dialysis. Now, I have absolutely no experience in managing pediatric patients unless it is heart related. And even that was 4years ago. So instead of hoping for the kid to be referred to another better equipped hospital, my mind decided to be selfish and still wanted the admission so that I can prove myself capable. My mind was so fast in starting the chain of thoughts of what all should be done for the kid when he arrives to the ICU, and didn’t really think of how shitty a person I have to be, to want to prove myself worthy at the cost of a child’s life!? I came upstairs, informed the nurses about the possible admission, got them all ready and told them to indent a dialysis line for pediatric patients since he may need one, and the one we use in adults are longer, and we have pediatric admissions only once in a blue moon.

So fast-forward to 5pm, the Gods decided to shit on the chill atmosphere in the MICU and 4 patients were rolled in together. One from the ward kay she got sicker and was breathless for some reason, two new patients who were to be admitted in the cardiac ICU but instead got sent here kay that ICU was being fumigated and we had empty beds in my ICU, and the last being the kid i saw in the ER earlier. While my co worker decided to be AWOL at that exact same time I decide to rush to the kid first while ringing him. Started taking the history and realised how inadequately the kid was being cared for, be it by the parents or the multiple hospitals he was admitted to over the past couple of years. Only now I regretted my thought of hoping him to be admitted here despite knowing full well that he will not receive the care he needs at this hospital cuz we don’t have a dedicated pediatric department, and the staff and doctors here aren’t capable of dealing with kids. We all had sympathy for the kid. From the housekeeping staff to random relatives of other patients. Even doctors from the ward who usually are nowhere to be seen even when someone’s dying in their ward, showed up to see whats up. At one point I had to sternly tell all of them to leave so that we can do whatever we can cuz sympathy ain’t doing shit for the kid. The MICU tag and the security that works here are a big joke if the doctor on duty has to do crowd controlling also. But yea, after I took all relevant history and talking to the consultant nephrologist, I told the family that the kid needs dialysis cuz the creatinine levels were alarmingly high and he had severe metabolic acidosis, both indicators for urgent hemodialysis, or else their kid will die. Something no parent wants to hear. But my mind didn’t have space for sympathy or for feeling sorry for the parents, and went straight to the point. In between all this my coworker decided to pop up, enquire abt the case and then went to deal with the other 3 new patients, Right after getting the consent for inserting the line and intubation, I sent the family away and asked the nurse in charge about the status of the pediatric line we had asked for. The pharmacy informed her that they only had one line left, and that too an expired one. First of all, I didn’t realize there were expiry dates for lines. But then again I noticed the same thing 4 years back when I saw expiry dates printed on IV cannulas that I used to put in kids. Didn’t think much about it and called the consultant right away to inform how ill equipped we are at handling the kid (lowkey ranting, so we can refer him to a higher center while he’s alive). But the consultant was equally amused by the expiry date and told me to insert one nevertheless as he didn’t expect the kid to survive for long if he doesnt get dialysis right away. Now, mind you the process of inserting a line is more or less the same in everyone, adult or kids. But if you really think about it, how big is the lumen of an adult IJV? Small right? Now think abt the same for an 8yr old kid who is below the average growth rate for kids his age. Got extremely scared about fucking it up and called the consultant intensivist for suggestions. Instead of giving suggestions, dude just told me that there’s no one in my city who puts lines in pediatric patients and even the equipment is difficult to procure. Whatever little confidence I had mustered up went down the drain. He told me that he has never done it himself but knows that people do it in the femoral vein instead of the IJV since nobody wants to prick the neck region because of the small anatomical area and the proximity to the carotid. I then called the primary consultant again to inform him that I’ll be putting a femoral line but he, without a pause told me to go for the neck. I should’ve known better and not called him at all cuz he has a history of being worried about catheter related infections in his patients, and rightly so. People can die cuz of that. Should have just avoided all the risk and stress, and put in a femoral line…

vp.

[therantingdr]

31.

Little did the fly know that once he got out of that pressurized cabin, he'll be in a completely new world, away from his family and friends. Poor guy's gonna be so lost.

vp.

[therantingdr]

30.

Came across some of the old photos, and it reminded me how happy we were even when we didn't have much. The unpolished walls, the messy sofa covers, the old socks and sweaters of our school uniform that we'd wear at home for winters. But in spite of all that, I always found 4 people doing the most random shit together, happy. Every single picture.

Things have changed over time. They made sure we went only uphill (Nope, we weren't poor. But not rich either). It's funny how life has passed me by, and I keep forgetting that it wasn't the nice and expensive things around me that made me happy. It was the company I had.

Oh, also love how we still have most of the things from our childhood. Credits to amma for that.

vp.

[therantingdr]

29.

Oh, a menace to society is what i would be, if i was in my right mind. The hint of depression sprinkled on my personality keeps the world safe.

vp.

[therantingdr]

27. Trusting My Hands Again

Putting in dialysis lines has become an everyday thing for me now. A while back, I was doing a difficult one, and...let's just say things didn't go well. No one could tell how the patient deteriorated or why things turned out the way it did. But somehow, I felt guilty about it. Yes, I couldn't convince myself that what I did resulted in someone deteriorating, since there was nothing that could prove to me, or to anyone that I did something wrong. But I couldn't convince myself otherwise either. I just felt guilty but couldn't put a finger on what went wrong. Since then, it was like I didn't trust my hands anymore. I then promised myself not to touch a patient if I wasn't absolutely confident my intervention could help them. But that meant shying away from anything difficult. Been 2 months since that incident, and I still find myself thinking about that patient, trying to find something that could tell me why her condition went sideways. Been slowly working on regaining my confidence since then.

Last duty, I had a patient with some sort of undiagnosed anxiety disorder, and he needed a central line. The basic procedure for both a dialysis line and a central line is, more or less, the same. It took nearly 2 hours for me to convince him and his wife why he needed a line. She even went behind my back to call the consultant and forced me to talk to him after I explicitly told her that the consultant doesn't need to be called at 10pm for such a thing. Anyway, they somehow agreed, and I went on to check the vein using an ultrasound and realized that it's a difficult one. I couldn't back out now. Not now. Not after hours of convincing. Even the consultant had told me to do it and not leave it for the incoming doctors. Sometimes, I just hate being one of the seniors. But that's a rant for another post. So yea, it had to be me.

I could feel my hands trembling, and the patient telling "I trust you, sir. I trust you" didn't help either. Maybe it was his way of coping with the fear, to put his trust on me, or at least trying to trust me. I remember giving him a bit more local anesthetic than I usually do, as if that would prevent him from deteriorating if I messed up. Took a deep breath and went in slowly. The vein was dancing around since he had been pricked multiple times before this admission, so the fascia around the vein wasn't exactly holding the vein steady, and it was collapsing with each breath he took. And he was breathing HEAVILY. Somehow, timed it well and peirced the vein right when it dilated, and cut the angle of the syringe down right away so as to minimize the risk of going through the vein. All that was left was for me to pass the guidewire, and then the difficult part of the procedure would be complete. It went in smoothly. The smoothest it has ever gone in, in my time here. The relief on my face was probably pretty evident as even the nurse pointed it out. And the long breath the patient let out after I told him it's done told me he too was relieved.

Such small victories are, I guess, important if your confidence was once shattered and you are trying to regain it. And to me, it was exponentially more important given the field I want to build my career in.

Maybe it's time I trust my hands again.

Oh, all this didn't stop me from being annoyed that I had to stay an hour and a half after my shift. Cuz fuck that!

vp.

[therantingdr]

26.

Sick of getting dick pics on whatsapp.

Okay, maybe it's updates of the patient with Fournier's gangrene, but still ehhh!

vp.

[therantingdr]

25.

Excerpt from 'This is Going To Hurt'

"One brilliant consultant tells her trainees that by the time they retire, there'll be a bus full of dead kids and kids with cerebral palsy, and that bus is going to have their name on the side. A huge number of 'adverse outcomes', as they say in hospitals, will occur on their watch. She tells them if they can't deal with that, they're in the wrong profession."

Maybe if someone had said that to me a bit earlier, I'd have thought twice.

vp.

[therantingdr]

24.

So, apparently, curd causes pneumonia. And a patient's family threatened to file a criminal negligence case against me for allowing curd to be served to that patient.

The fact that he was ignorant and yet so confident about it confused me for a while whether to try and explain the facts or just let him be. Unfortunately, I chose the former, and that pissed him off, following which he went off on how he's from an influential family of doctors and asked me not to try and deceive him. I sighed and just gave up.

vp.

[therantingdr]

23.

It's been quite some time since I had my life planned out. Like something to look forward to. I used to live off such short-term goals back when I was in medschool. It could be the next training session, a date with her, or the next tournament, etc. Since graduation, life has been so uneventful that I tried to distract myself from feeling the need for such goals. But today, when I was casually thinking about random shite, it occured to me that the rest of my year has planned itself! I didn't even mean to be this occupied. 😂

So, I've got two exams coming up, in late June and early August. Then I have my friend's marriage in Sept, then gotta go home in Dec. And somewhere in Oct-Nov, I gotta plan the trip that I've been wanting (and serious about). In between all that, I have another friend's marriage, and I'm planning to move to a different city cuz I'm kinda done with this one and I know I wont clear NEET this time around either. And poof! The year's done!

vp.

[therantingdr]

22.

All it took were a few texts from that person for my mind to start its usual mental gymnastics again. Now everything she says, everything she posts, every story of hers, every song she sends, every reel she shares, has a meaning behind it. It's funny how your mind tries to interpret everything according to whatever phase your life is in. And you don't care to stop it even when you know it won't end well, because it never did before. You know you're getting played by your mind. Yet you go along with it as it reminds you of the days you were once actually happy and at peace.

I think the easiest thing to do is to just let it be. The more you try to control it, the more you encourage it to overthink. If it feeds off the happiness a text gives, then let it. It's like letting your kid loose once in a while because you know... you know they would eventually come back to you. Maybe your mind needs a bit of 'letting loose'.

vp.

[therantingdr]

21.

These medical TV dramas led me to believe that we, as healthcare professionals, actually indulge in deep, meaningful conversations about the patient's quality of life and their wishes. Yes, I was naive back then and expected everything in life to be ideal and perfect. Like, they used to show resident doctors fighting with each other, with all their might about why the patient can't be resuscitated because he has 'DNR' tattooed to his chest, or nurses actually giving out life altering advices to patient about their personal lives. Oh, I always hated that one show in which that one resident who would get too close to the patient (or their family) and literally whisper while talking to them. Like dude, talk like a normal human being, ffs! I get uncomfortable if someone even stands a bit too close. And here you are, getting all touchy and shit. And another one where they show doctors paying a visit to the house or work of almost every other patient they see to look for clues for their diagnosis. That was a bit too much, even for me. But yea, basically, they led me to believe that we have the time and energy to actually care THAT much.

Fast forward a few years down the line, now that I'm actually working in a critical care unit as a doctor, we barely get time to even hydrate ourselves, let alone discuss a patient's personal life. There has never been an instance where we actually 'discussed' if a patient should be resuscitated or not. It's simple most of the time. If the family tells us not to, we don't. If they don't tell us anything, we do. That's it. Yes, we do try to explain how bad things are, the possible consequences of CPR, and what we expect out of it just so they can make an informed decision. But that is it. I've never seen our nurses get involved in a patient's personal life either. They barely sit during their shifts for godsake! How are they going to find time to chit-chat with their patient or his/her family!? We try not to make it too personal, and once our shift is done, we try to leave the baggages of the day at the hospital itself. Cuz no matter how hard the society tries to portray us as saints (when in a good mood), at the end of the day, we are just as human as the patients in front of us.

In a way, I think it's a blessing in disguise that the medical systems almost everywhere in the world are so overburdened that we have basically turned into bots that just follows protocols and norms and not get too affected by every patient we see. Because if it weren't, we'd have time to care more. And caring more would eventually crush us, given how heavy these emotional baggages get even when they aren't ours. So yea, maybe bots are better.

vp.

[therantingdr]

20.

The sense of calmness and peace I felt when I was being bogged down by the thoughts of how bad shit's been in almost every aspect of my life and out of the blue, my mind reminded me that it's going to be alright cuz everything eventually falls in place anyway. Oh boy!

Such moments I feel can't be forced. I dont think you'd feel the same if you consciously remind yourself that it's going to be alright. It may feel a bit good, but not thisss good. It has to be natural.

Guess you just got to be thankful your mind can sometimes pull that off and get back to hustling.

vp.

[therantingdr]

19.

This urge to pursue the PLAB pathway even after losing the only reason for it is something I don't understand. Maybe it's like doing something in honor of someone who couldn't do it with you (No! They didn't die, eh!)...idk. Yes, NEET PG is tough. But I genuinely back myself to clear it. Then why do I feel the need to PLAB? It's confusing.

vp.

[therantingdr]

18.

I started reading books as a hobby about 4 years back and have managed to finish a few with whatever little time and energy I could give. Now, apart from a few of them which I may read again (just to see if I can give it a different perspective), all others are just gonna stay in the shelf, never to be read again by anyone.

Makes me want to give it away to someone. The only problem is that I got very few friends, and they never gave me the impression that they enjoyed reading as a hobby. Idk. I don't want to give it to someone who would just throw it on the table and never look at it ever again. Want to give it to someone who would value it, read it, and pass it on to the next person who would value it just the same if not more.

vp.

[therantingdr]

17.

Back on duty after a 2 week long vacation. 48hrs shift. Just doesn't feel right. Maybe it's just that feeling that everyone has on their 1st day back at work after a long holiday. But this one also feels more like 'I don't wanna do this for the rest of my life' kinda thing. This (🤏) close to quitting my job.

vp.