Friday, 27 December 2013

"You have to be brave" - What it's like to work in a hospital

Dr. Apollina Sharma still remembers what it was like the first time she assisted in the delivery of a baby in a hospital.

"I was very scared during my first delivery because I didn't have someone on my first time to actually show me how to do it," she recalls.

"What is the method to hold the baby, what is the method to pull her out, where do you have to place the baby so it doesn't have an extreme rush of blood coming from the mother."

"I had no idea what was going to happen," she recalls. "All I knew was that there is this woman and there is this baby that is going to come out and I've read the birth process in some book."

Before the baby is born, doctors are meant to check for cervical dilation. This is done by placing the index and middle fingers at the entrance of the woman's birth canal which should measure about 10 centimetres before delivery

"Unless you've not done this in previous cases, you'll never be able to estimate that centimetre dilation," she says. "I had no experience in doing that so I was scared."

"When the head came out, my mind just went blank," she tells me. "Somehow I positioned my hands around his head and I tried pulling. Thank god a nurse was there to motivate me!"

"The thing is that he had a cord around his neck and that's a very dangerous situation and the cord has to be taken out immediately," she continues. "I'd only read that in a book, I did not know how to hold the baby and take the cord around as well.

"The nurse had to swoop in and hold the baby and it all has to be done in a matter of not more than one or two minutes. You have to pat the baby in order for him to get oxygen within the first five minutes (of his life) otherwise he can go into cerebral palsy."

"I cut the clamp, baby cried, I was happy, and I was like 'thank God, no more deliveries until I get OBG'," she says, her voice rising in exultation.

Apollina with a baby she helped deliver. The hospital delivers between 23 and 25 babies a day but she vividly remembers the first one she delivered. Reproduced with permission
Last summer, Apollina Sharma graduated as a fully-qualified doctor. She's spent the last year or so interning at three government-run hospitals in the Indian city of Mangalore and is taking me through the emotional, physical and mental challenges she went through during that year.

Her surroundings play a great role in making her feel at ease. We're sitting in a coffee house that's located by the beach. The sun is setting in the distance while in the backdrop is the glittering skyline of the city of Muscat Children enjoy a kickabout on the beach while parents take a walk by the seashore. 


'You don't have a choice'

I've brought with me Dr. Zarshis Avari to help decode some of the medical jargon that is going to come my way. He's a bit miffed, because he'd rather be at home watching Manchester United play Newcastle on the telly.

listen to ‘Apollina on how her father influenced her decision to do medicine’ on Audioboo

"When a patient comes, depending on how critical his condition is, you have to [stay], you don't have a choice," says Apollina. "You have to stay there, that's your duty. You signed up for the job, you have to do what you've been assigned to do. That's your duty as a doctor.

"If you have a patient on a deathbed who requires your attention, that's your first priority because that person needs you at that particular point of time. There's no choice there. It's a part of your work.

Related article: No place for emotions in medicine

Apollina still remembers how much she was looking forward to working at the hospital at the start of her internship, a rite of passage for any qualified doctor. 

"You're happy and you're prescribing but I think after six months you realise that it's not as rosy," she reveals "You have to learn a lot."

That hit her in the face when she had to answer to the family members of patients who had not been able to overcome their afflictions, she says.

"Also, especially in India, you've a lot of people who are illiterate," she explains. "They don't necessarily know exactly what's right or wrong for them so you have to end up taking decisions out of the treatment options for them.

That's a very big responsibility because you're basically taking charge of somebody else's life."

'You do feel frustrated, you do feel angry'

"There are a lot of doctors who basically don't view patients as human beings," she says. "They view them as objects that they can learn from."

"They just charge them with their medicine, start putting needles in them, start examining them, start doing things on them," she explains. "The population's illiterate, so they they don't know what's going to happen and they just blindly follow whatever the doctor's doing.

Apollina during her stint in community medicine, instructing school children on medical safety. Reproduced with permission
Apollina says that her moods at the end of each day would depend on what she'd done at the hospital that day.

"There were days when I used to feel extremely happy," she recalls. "You've really helped somebody. I had a lot of patients who came in with liver disease. 

"Taking care of them and trying to counsel them, and when you see them get better over a period of time, it makes you happy."

Related article: Old people just need company

But there were obviously days when she would come back exhausted. "Because there's lack of doctors, your 12-hour shift gets pulled to a 16 hours, 18 hours. We don't have enough interns to match the population that comes in.

"It's not like the next morning when you go on rounds when the senior doctors ask you for reports, you can't be like 'my shift ended 12 hours ago and I went home because that's the end of it'. That's not a reply you can give to them," she says. "You have to be accountable for your work."

"At that particular time, you do feel frustrated, you do feel angry, but at the end of the day, you do it with the mentality that 'tomorrow, my patient is going to be better'," she concludes.

'Medicine was very interesting'

Apollina's taken a liking to a blueberry muffin that's sitting in the display window of the coffee shop we're in. Five minutes later, it's microwaved version is sitting on a ceramic plate in front of us. After 12 months spent primarily subsisting on rice cakes and lentil soup, she's practically inhaling this muffin.

She takes me through the different departments she spent time in.

Her first month saw her posted at a village as part of Wenlock Hospital's community outreach programme and along with learning what it was like to work in a village, she also learnt how to deal with shooing away scorpions and snakes where she used to "do something with a stick and run."

After another month spent in a suburban community, she spent two months in surgery. Although she was not allowed to perform major surgeries as in intern, she did perform minor amputations and learned how to suture and dress burn wounds.

Paediatrics at KMC Attavar Hospital came next and she learned "about little babies and how to treat them when they have jaundice and congenital defects." in addition to spending some time in the paediatric ICU.

She becomes quite giggly while telling me about her time at orthopaedics because "orthopaedics is full of guys, so the minute they see a woman walk in you get the least amount of work."

But she remembers her time in diagnostic medicine at Wenlock most fondly.

"I got to see a lot of great cases," she recalls. "I had this one amazing case. Nobody could find the diagnosis and it was something as simple as a loss of potassium in the body and the patient had gone into complete paralysis."

"Medicine was very interesting," she says. "It was about getting all these different concepts you've learned and trying to place everything together and trying to apply it on a patient."

"When a patient comes in, he's not going to have all the symptoms listed (in a book). A patient can come in with completely different symptoms and have a completely different diagnosis.

Zarshis is now getting fidgety: it's half time at Old Trafford and there have been no goals at the Theatre of Dreams so far.

'I've delivered a baby with my bare hands'

Diagnostic medicine aside, Apollina vividly remembers her time in the maternity wards at Lady Goschen hospital.

"The hospital, half of it was under construction," she recalls. "So all the wards were clamped into one. "Our entire hospital was structured in such a way that you would have women sleeping in the corridors. There would be no space to walk."

"There were beds in the corridors because the thing is, when a pregnant woman comes, that's the government hospital for that particular region, you can't send them anywhere else," she tells me.

Apollina (centre) and her fellow medical interns, who often had to pull 18-hour shifts at the hospital they worked in. Reproduced with permission
Government hospitals in India do sometimes face acute shortages of both staff and equipment and it was the same where Apollina worked.

In fact, 40% of India's primary healthcare centres are understaffed.

A phone call to Lady Goschen Hospital a few days after she'd spoken with me confirmed what she'd said. Both KMC Attavar and Wenlock Hospital were unavailable for comment.

"Because we were so understaffed, what used to happen was that I would be delivering a baby and the other baby would start coming at the other end," she says. "I would deliver this baby, run, rush, deliver that one, deliver the third one, deliver the fourth one.

"I was not changing my gloves. I've even delivered a baby with my bare hands because we just didn't have gloves to wear."

"Illiteracy, it plays a very big role especially in the delivery room," she continues. "We once had this woman who was told by an ayah (nurse maid) in the village that she came from that the best way to deliver to sit on the floor and squat down."

Standard procedure during delivery is to place a patient in the lithotomy position and then perform an episiotomy where the wall of the birth canal and the protective layer that covers it are slightly cut to allow the baby unencumbered passage through the birth canal.

Diagrammatic representation of the lithotomy position in which women are placed before giving birth. For informational purposes only. Image courtesy Saltanat Ebli and Wikipedia 
"You won't be able to do that if the woman is squatting down and she was reluctant to get on the bed and this was at three o'clock in the morning and we were working since six o'clock the previous morning," recalls Apollina.

"When a patient comes in and she's doing all of these particular things, she's not getting on the bed, she's acting crazy, she's throwing things around, it gets very difficult because at the same time you have to be a doctor. You can't hit her. You can't forcibly take her on the bed against her will."

"We had to sedate this patient and then give her a C-section." About 23 to 25 babies were delivered at the hospital every day.

'I learnt the basics of what it takes to be a doctor'

Working long hours in a hospital takes its toll on any medical professional. Apollina says her primary method of unwinding was by sleeping.

"For the most part, when things got really hectic, all I would think about was my bed," she says with a laugh, while Zarshis nods in agreement. "Sleep is a very uncommon commodity."

"It was basically just getting enough sleep and getting some good food," she continues. "When you work for so long, you think of basics. You want something good to eat and you want a bed to rest on. For most of my days, that's what it was."

Looking back on her past year, Apollina says she learned a lot. "I used to think it's very simple: you see a diagnosis, you give medication but its a lot more than that," she says. "It changes you as a person when you actually go through another person's problems.

"Sometimes you get scared in situations and trying to overcome that fear in order to get the confidence, that's important, and also practising what you learn is also extremely important because that's the only way you're going to be good at it."

"I've grown as a person," she says with a wan smile. "I've actually learned how to get through a very tough day and be able to smile at the end of the day."

"You have to be brave," she says in closing.

Apollina now plans to move to Canada to earn her MD, she gives me a hopeful smile as she plans for the future. Across the table, however, Zarshis Avari is wearing a scowl like thunder. It's not because he's had to listen to so much of what he already knows for a good hour.

It's because Newcastle United have scored at Old Trafford.

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