Part 1 : The Beginning

The posting had come to an end; things were in place. I, the senior resident had prepared the patients for handover, which meant tiny details had been taken into account. Even the tiniest of flaws had been corrected. It was all that mattered then.

It was all that was important.

I had a sense of contentment as I was heading home, relieved, almost satisfied. The only task now at hand was to find out how the patient in CCU was doing. After all, we had revived her after CPR—the so-called “post-CPR” patient—and we all knew that these patients carried grim prognosis. Tanya, my JR3, had checked on her only a few hours back. I was still obsessing about that patient when my chain of thoughts was broken by my cell phone ringing.

Most moments in life just exist, others evoke, but some define. Define everything that happens from thereon. These moments haunt us not because they are petrifying but by just being there.

I heard CPR and Tanya.

It made no sense to me. It took me three phone calls to register that it was really her who had had cardiac arrest. All events in life need a linear narration, but for some reason however hard I try I cannot recall the time between receiving the “call” and the time that I saw her next, which was in the trauma centre. She was lying on a stretcher in her grey pyjamas and sky-blue t-shirt. I checked her pulse. It was strong and steady.

Thank God.

The stretcher was surrounded by a crowd of residents extending beyond the doors of the casualty room. People were throwing instructions as well as comments rather carelessly. Someone told me that she had injected vecuronium—a paralytic agent—while someone else added other intricate details. I did not care about that stuff, at least not in that moment. As I took over the Ambu bag, I noticed her brown nail polish—she had bought it a couple of days back. All she needs is a ventilator, till we nurse her back to health. I thought to myself.

It was all that was important now.

The next couple of hours were spent making her comfortable in the ICU bed (third bed from right in the first wing). Tube in situ, two IV lines and catheterization done. I noticed the anaesthesia team had started noradrenaline. Maybe she needs a little more support than I had anticipated, but whatever she needs to get better. I thought to myself again.

The settling part was smooth. Everyone worked like parts of a well-oiled machine. Because that was all we knew how to do. No one knew what to say or feel or do besides the medical stuff we had been taught so well over the years. No one had prepared us for this.

So, I just stood there unprepared, as more friends came, seniors and juniors came, other doctors came and authorities gathered to decide the official course of action. By this time all segments of the story had been pieced together. People were of the opinion that the amount of hypoxic brain injury cannot be predicted and only time will tell the damage she has sustained. If the cardiovascular system has been revived in an unwitnessed arrest, then the chances of brain injury should be negligible, I reasoned with myself. So, she needed time.

It was all that was important now.

People had vacated the premises. I checked my phone—it was midnight. There were messages and missed calls from friends and strangers. Whether they were seeking comfort or offering solace was hard to say. The one person I wanted to speak to was Dr S, our resident supervisor, a mentor, a guide, a confidante to both Tanya and me. Unfortunately, she was on a flight, midway between the sky and the soil, unaware of the events that had unfolded. So, I spoke to no one.

I sat next to Tanya, looking at her brown-coloured toenails and wondered if the course of events would have been different if I had done something different or differently, anything. In my head I ran and reran the conversations we had had and the time we had spent together as I watched her vasopressors increase and life support intensify. Sometimes reflexes can return after twenty-four hours. Some more time and she will bounce back; I tried to convince myself. So, she needed a little more time.

It was all that was important now.

At the break of dawn, I found myself inconsolable. Watching her slip away through the night had finally hit me. The thought that she may not come back had started to take shape and was turning into a possibility. At that instant other questions that had been hiding behind the chaos of it all began to crop up.

What was she thinking? Was it an act of impulse or desperation? Did she regret injecting seconds after she had injected, like we have been told people do? It must have hurt her, terribly. The air hunger. Oh, the air hunger!

And then came some other questions, which lay in the moral grey area. Was this what she really wanted? If yes, then doesn’t she have the right to get it? Shouldn’t taking control over one’s life be left to one’s own discretion?
I wanted to wake her up and ask her if it was help that she needed to get over whatever was troubling her (we all would have helped her, each and every one of us) or approval for the decision that she had already made, after careful consideration of all the possible options. After all, she was smart and had probably planned it for a while.

It was just wishful thinking. She was not waking up any time soon.

Amidst these unanswered questions that hung in the cold air of the morning, my thoughts began to overwhelm me and I decided to reach out to my off-limits support system, Dr S. I dropped a message, hoping to get the familiar “what happened” on my screen.

There was no reply. So I dropped a couple more messages with the urgency that the situation demanded.

Still no reply.

In an attempt to maintain my sanity, I headed home for some food and some much-needed sleep. Little did I know that the couple of hours of sleep that should have brought solace would be infected with thoughts that could only be described as dreadful, to say the least. So, I was back to square one. Back to the chair that faced her, from where the monitors were visible and the alarms audible.

The second night was exactly the same as the first as far as lingering thoughts were concerned, but it was the exact opposite in terms of her prognosis. Death was now a matter of when rather than if. Isn’t death always a matter of when rather than if? I thought. We needed time now.

It was all that was important now.

I felt a little better. Maybe the impact of the event had softened by now or maybe it was just acceptance that had begun to set in. Or maybe because I had finally heard back from my supervisor. The messages had gone through only after she’d landed. But now she knew. And even if she couldn’t fix things, at least she knew.

The next morning, I had a feeling of impending doom. I had to go to work and treat patients, relieve them of their miseries while my colleague, my friend, my junior lay there just minutes away from death. Wounded healers, we are aptly called.

Somehow, I knew for a fact that if I left her side she would go into arrest. It was neither reason enough to convince people to let me stay nor was it an argument backed up with logic. The universe did not revolve around me. Maybe mine did. What was bound to happen would happen, now sooner than later.

The course of events unfolded just as I had predicted, moreover feared. She had an episode of ventricular tachycardia. I rushed back to her following a series of nerve-racking panic attacks. So, I was back to square one. Back to the chair that faced her, from where the monitors were visible and the alarms audible.

I sat there motionless as I witnessed her deterioration. She was so adamant, so stubborn, and no matter how hard we tried she was not ready to come back. Between what seemed like endless cycles of CPR, I began to wonder if she had suddenly started looking peaceful.

She was declared dead shortly thereafter.

I had held her hand throughout the failed resuscitation. Ironically without even realizing until it was time to let that hand go. Another moment that was bound to haunt, by just being there.

We all gathered to watch her being wrapped in a clean white cloth. Toes with brown-coloured toenails tied together, nostrils plugged with cotton balls. Just like that she was not HER anymore. We put flowers over the clean white cloth. I guess that is something people do to validate death.

Validation of death.

It was all that was important now.

—

I left the hospital that night and felt something settle over me. Something dark, heavy, real. A shadow not of my body but of my mind. It followed me home. It followed me back to work the next day. And the next. And the next.

—

A few days later life seemed to get back to normal, whatever that means. For ‘normal’ is a word that I can no longer define. There is a fine line between addressing a problem and allowing it to completely devour one’s existence. So many unanswered questions, unfinished discussions, unexecuted tasks, unachieved goals, unaddressed issues and unprepared people were left behind.

A week later I found myself signing off the discharge card of the “post-CPR” patient who was admitted in CCU. It read in clear coherent words: Patient is being discharged in satisfactory condition.

Part 2: The End

I entered the labor room and headed straight for the thumb-print attendance machine, resisting the urge to disconnect it once and for all. I pressed my thumb against it and the machine said thank you in its monotonous yet reassuring voice.
I turned around to find my shadow standing right behind me. It was profoundly dark, deep and real. A shadow not of my body, but of my mind — cast by the recent, ghastly, larger-than-life events. The mind has such a fragile, delicate existence that even something as innocent as a word or a mere look can destroy its peace. This, however, was an incendiary event, powerful enough to burn lives. The mind had no chance of maintaining its integrity.

The dark, deep shadow was conceived of profound grief. It was benevolent enough to accommodate other feelings as well — guilt, remorse, regret, anger, hopelessness, helplessness — all gladly made their way in, making it a darker shade of black. The smile on my face was bright, shallow, fake. A biting contrast to the shadow standing right behind me.

I picked up a sheet of paper to take over from the morning team — a tradition that marks the end of everything else happening in the world and signifies the beginning of a zone where only we and our patients reside. Two patients per bed. Two files per bed. Two plans of management per bed. Both teams glided effortlessly from bed to bed, exchanging neatly stacked paperwork, strategies, ideas — the orderly, methodical, businesslike procedure in biting contrast to the turmoil of the mind. The insides did not match the outside.

There is always a great deal of certainty in the uncertainty of the labor room.

I was busy managing patients, still very aware of the shadow behind me, when I heard chaos from the operation theatre. The patient was a twenty-five-year-old female with a previous caesarean section, being operated for acute fetal distress. I rushed into the OT — my shadow following closely — to witness the pandemonium of a morbidly adherent placenta.

Everything and everybody in the OT was in constant motion except the patient, who lay completely still, save for the rhythmic rise of her chest as she struggled to breathe. The operating surgeon held the exposed uterus with its morbidly adherent placenta. It looked fierce and angry — a hungry, uncontrollable monster — spurting blood from multiple arterial mouths in all directions. Dry sponges were passed quickly; sponges dripping wet with blood were returned just as quickly. Blood coloured the drapes covering the vasopressor-supported, intubated, pale white patient a bright red.

For a moment it seemed like the monster would devour its victim and leave the rest of us with unforgiving shadows that follow. The outside commotion now matched the inside disorder.

How are we even going to save her? Are we even going to save her?

I was asked to call the ambulance to fetch Dr S, which I did without wasting time.

Dr S was the consultant second on call. Those who loved her loved her immensely. Those who feared her feared her with the same intensity.

She had eyes that conversed. Eyes that made statements and asked questions. With her eyes alone she could unravel incidents, decipher situations. She always knew. The residents knew she always knew. So when she was around, no attempts were made at hiding things — only at rectifying them.

Her eyes did little to hide her own emotions. They declared her approval and proclaimed her discontent long before her words could. She had the aura of a healer — an aura that invited people to come and stay, offering solutions to all problems. Personally, I always felt I had something extremely important to tell her, though what it was I did not know myself (and still don’t).

Conversing eyes. A calming aura. In contrast.

Soon enough she was scrubbed in, taking control of the wild uterus which had already consumed four units of packed red blood cells, four of plasma, and was still thirsty for more. Her hands moved swiftly and synchronously. The surgery progressed flawlessly. The eyes scanned. The hands cut. The mouth instructed. The assistants assisted.

I stood there observing. Had a human life not hung in the balance, I would have marvelled at the progression of the surgery — nothing short of a well-timed orchestra. Dr S looked at me: aren’t you going to get washed?
An amazed resident and her dark, deep shadow replied, “yes, ma’am”.

I scrubbed in. My shadow scrubbed with me. I held the retractor as clamps were applied and the bladder separated. In an instant, the uterus lay in a tray at the foot end of the patient. The defeated monster looked calm, quiet, almost helpless. Its fate now was pathology — to be cut open and examined, to ascertain why a once friendly organ had gradually turned monstrous.

I wondered if people, too, could be sent to a laboratory — to ascertain why the friendly ones turn into monsters.

She spoke to us about nothing in particular, and yet about everything in detail. Her eyes — the only visible part of her face — spoke with her. I listened carefully as the world began to shrink. Shrink to the size of the OT table. The ambience she carried spread slowly through the room, like invisible incense, filling it with solitude and tranquillity. Everything and everyone in constant motion had come to a still.

The surgery was successfully concluded with the last of the skin sutures.

The OT looked like a battlefield. Dirty mops, gauze pieces, blood stains, tissues, consent forms, used vials, syringes, cord clamps littered the floor. And yet, there was an unmatched cleanliness to the morning. As I watched her leave, I wondered what had changed.

I walked out with the stabilised patient, headed to the thumb-print machine, and pressed my thumb against it. The machine said thank you.

I turned around.
My shadow was gone.

The mind — fragile and delicate in its very existence — had been healed, for now. The insides matched the outside. The shadow had turned to smoke and disappeared. The monster had been conquered.

Two lives were saved that night.

Vartika Mishra is an obstetrician–gynecologist in private practice. She trained at one of the largest and busiest government hospitals in India. Her creative nonfiction has appeared in Hektoen International, KevinMD and In-Training, and she has sixteen academic publications, including two in the BMJ. When she is not busy helping babies come into the world, she writes about her days in residency — the absurdity, the exhaustion, the patients who stayed, and the friends who made it survivable.