Medicine and Intention
Every afternoon, a white ambassador car stopped on the far side of the road, took a sharp right turn into a narrow passage which may have looked like an inverted question mark to the intelligent crow of the folk tales. It led up to a house, humble and hidden beneath the bend of a laterite hillock. The dogs of the house recognized the car, although white ambassadors were more than many, they would run to the gate and bark, alerting our help, who trundled towards the gates. The driver’s profile is partly visible from my hiding. Her hair was plaited and pulled back into a tight bun with pins and she wore her stethoscope around her neck over an unfashionable saree whose blouse suffered from want of style. Everything about her suggested modesty, yet there was an air of superiority that came with her own appraisal of the hard work and intelligence she practiced and possessed in order to reach where she was. This is my first and the oldest memory of my grandmother.
As my grandmother brought the car to a halt I came out from under the canopy of the garlic creeper, my secret; if I don’t , the dogs will find me and reveal my hiding.
It was time for lunch.
The conversations at the lunch table were more often medical in nature. Grandmother was a gynecologist and obstetrician, a surgeon, and taught students of the medical college when she was not in the OP or the OT. Regardless of my presence, she and grandfather discussed difficult diagnoses and consulted each other on surgical decisions. I must have heard the words labor, hysterectomy and prolapsed uterus many times at lunch. I put together pieces of the conversation like a puzzle to imagine the thing called ‘catheter’. Cold objectivity cut through our meals like a hot knife on butter. “Were there no people?” I wondered, for I only heard them talk about patients or cases. This must have left a memory in me that I asked her once. She said,
“ A surgeon must never form a relationship with the patient. She has to see organs as organs and diseases as diseases”.
Unlike the poster grandmothers exuding warmth and kindness, my grandmother was strict, immaculate and therefore difficult to like.She kept a sterile house and a clean body. Yet she contracted many diseases from the hospital. One summer when I spent my summer vacation with her, she joked about adopting me as her daughter. I was terrified of this absurd prospectus and desired to run away to my home, its imperfections appealing to me like candy.
She supervised the cutting of fish or jackfruit and demanded precision in both tasks.
She sewed her blouses. And when she did, she showed me how to draw surgical sutures and knots. The thread was pulled into tight, evenly spaced , meticulously precise stitches. According to her, a good surgeon is one who leaves the body as though it has not been touched.
Grandmother always maintained protocol. I observed a strict adherence to procedure as she described the steps to me, … sterilization, preparation, anesthesia, incision… She was hard on nurses when they made mistakes, as well as her colleagues and student interns, but more than that she never forgave herself for even the smallest mistake she made. It was as though life was a leaf in one of her textbooks, predictable and yet ridden with risk. She did not appreciate change, surprise or anonymity. Perhaps, this too had to do with the surgeon’s temperament she maintained.
Endearments were to be sought elsewhere.
Giving birth to Leela pushed me into an intensely medical environment once again, for the first time after I left home. It was my grandmother’s advice and diagnosis that I desired most during my pregnancy.
She had lost her mind, by then.
She has Alzheimers.
Her last sane memory of me was when I was 2 months pregnant. My mother told me that she cried . She was angry with my grandfather and stormed out of the gate, saying ‘no one ever took me to see the baby’. I want to see Pooja’s baby’.
Then, she lost me.
Neurobiologist Susan Greenfield has done extensive research into what she calls the nuts and bolts of brain. She says that from our infancy, the brain personalizes itself based on the sensory experiences it receives and uses it to later demonstrate cognitive functions. To an Alzheimer’s patient, the number of such bonds available are very few and therefore, they tend to see, hear etc etc, yet not know, recognize, remember.
Grandmother forgot all the medicine, me, my mother and finally my grandfather.
I insisted on knowing every advice my grandmother gave my mother when she was pregnant with me. She had left instructions with Amma. “I've taught you ..now you have to teach Pooja”.
Indeed the experience of growing a life within you while watching one whither away is how bitter irony can be.
In honor of her , I decided to deal with labour pain with maximum dignity, and not make my doctor’s examinations difficult. And I did just that. My daughter also seemed to understand, she complied to my pushes and was out without tearing me apart. I imagined my grandmother assisting my doctor in labour, giving her relevant and timely advices. I remembered her deft hands and the knots she drew, as I lay on the labour cot, watching the needle and the catgut.
I have faith in doctors. I have faith in medical science, research as well as the latest developments in that field. I say this because the malignant skepticism and mistrust of that group by those betrayed has still not breached the respect I have for them. Very few jobs in the world are as exciting as diagnostics, surgery and medicine. The first time I heard the heart beat of the fetus growing in my womb, later when I discerned a face through the doppler scan, I thanked god for the advancements in technology, that I was able to see and someone was able to determine that the fetus was healthy. Although I didn’t get one, it was the reassurance of an epidural, an option to choose one, that helped me endure the worst of the pain. I was relieved to see a team of doctors and nurses to attend my labour as well as all the instruments that monitored our systems. Even if I didn't have any of these, I would still want to be in the hands of someone who I trusted to have enough knowledge and experience in obstetrics.
In the period through my pregnancy and post delivery, I found myself reading books that were set in the context of medicine in a way of seeking for clarity on what is happening to me, my offspring and my body. It was during the same time that I observed, despite the rising standards of health care, many still carried a vehement suspicion of their doctor’s intend and advice. The members of the breast feeding support group I was part of openly made statements such as “forget what your pediatrician says, their text books are old and many of them don’t know the latest advancements in medicine”. This would often be followed by hyperlinks to websites that people quoted as research evidence. They seemed to recommend a lactation consultant over a pediatrician as though it is the knowledge of medicine that has to be contained, suggesting that the doctor may be corrupt, or fallen for the lures of the pharmaceutical industry.
Such preferences are not surprising. Miracle fruits or barks that cure every disease from diabetes to cancer seem to be circulating commonly in social network sites. Several websites give information on drugs and their side effects appealing to the common man’ logic, in his language. Such information, without the doctor’s counsel, throws you far off. Once, Leela got runny nose, and I, being an anxious mother, immediately looked up the drug that we had bought over the counter. The website gave me information on several side effects of the drug, almost all of them being nearly lethal for a 4 month old. When her pediatrician gave her the same drug, I immediately raised alarm.
“I am not going to give this to my daughter without a satisfactory explanation”.
“ This is a perfectly safe medicine for babies. I am giving her a very low dose that you can take without fear. At the same time you must understand that a runny nose is better cured with steam inhalation, breast feeding and nasal sprays” .
Many of us do not take that small label on the drug that says ‘ on physician’s advice’ , seriously or understand how crucial that is. The doctor also said,
“ Please understand that it is not a doctor who dispenses the information that you find on the web. They are taken from textbooks, without any discretion and text books themselves keep changing. Being part of a large chain of hospitals, it is a hospital policy to update its doctors on all the recent developments in medicine, especially if it a ban on the drug”.
My doctor’s argument seemed convincing. I know how web content is generated. It is written ( copy/ paste/ format) by writers like me who are as ignorant of medicine as of rocket science.
Eula Biss compares our fears of medicine to our anxieties over industrialization. In her beautifully written book ‘On Immunity’ , she investigates the fear of vaccination she noticed among other mothers while she had a son, and provides a compelling complex narrative of issue.
“Our fears are dear to us,” she writes, and she parses these fears with kindness and complicity. After all, she says, she matches the profile of the kind of woman inclined to be suspicious of vaccines — white, educated, relatively wealthy — a woman drawn to doing things “naturally,” who tells us she gave birth without pain medication, medical intervention or an IV.
That “naturally” is key. Our anxieties about industrialization, at how we’ve polluted the world and presumably each other, have given the word its particular luster: “Where the word filth once suggested, with its moralist air, the evils of the flesh, the word toxic now condemns the chemical evils of our industrial world.”
The rising cost of health care causes additional worry among the sick and their kin. The skepticism towards capitalism mulls the trust of the common man in hospitals and its doctors, for health has become an industry. In a middle class left leaning society of Kerala, this adds another layer of mistrust that is adversely political in nature.
My grandmother often talked about a surgeon’s wisdom. It is moulded through dog years of learning and experience on the floor. She started attending cases when she was a house surgeon, watched surgeries being conducted by some of the best doctors in the country, picked up the scalpel strictly under the supervision of her seniors, studied through the night and passed exams, became a tutor, assistant professor, associate professor, professor and then head of the department to retire as a director. A surgeon’s wisdom is the capacity to make a judgement based on the presence or absence of symptoms. It is the ability to choose the right action, a strict discretion based on differential analysis of the case in point with the understanding that the call made can be as crucial as life or death.
The CTG showed a drop with every contraction, indicating fetal distress. The mother is tachycardic. A decision has to be made right there by the obstetrician whether to go in and rescue the mother and baby, or wait it out. Sometimes after going in, she may discover that the umbilical cord entanglement is not around the neck as they feared, but across the shoulder through the legs which may not be as threatening a the former. Yet, when a decision has to be made, it has to be made fast, based on all the faculties available to you at the moment. My grandmother also talked about the error of judgement that doctors have made. Gestational diabetes remained undiagnosed in a friend’s case and her baby died after delivery. Administering a glucose IV may have saved the baby. The less experienced doctor may not have been able to recall the textbook procedure or take a call in that intense moment. There are no miracles here, just plain Wisdom.
Recently, a friend was talking to me about a mysterious undiagnosable disease that put her well being at great risk yet the only manifested symptom was extreme fatigue. She did all the routine tests and had a change of doctors, none could establish what was wrong. Finally, a doctor was able to conclude that her adrenaline was set on overdrive after prolonged and consistent use of asthma medicines, plus several lifestyle changes she had made in the recent years. A simple change in diet was all it took to set her on the path of recovery, yet it took an expert doctor to identify her ailment.
At the best what we, you and I, are able to do is understand our symptoms, in isolation, that is if we are the best of the observers, and treat some of them. We can discern the actions of our cognitive mind yet when we begin to ask ‘Why?”, we do not know. We see our body as it appears devoid of its nuts, bolts, pumps and gears. What is our medical mind and body? How does a doctor see it differently than us?
“I learned a lot of things in medical school, but mortality wasn’t one of them. Although I was given a dry, leathery corpse to dissect in my first term, that was solely a way to learn about human anatomy. Our textbooks had almost nothing on aging or frailty or dying. How the process unfolds, how people experience the end of their lives, and how it affects those around then seemed beside the point. The way we saw it, and the way our professors saw it, the purpose of medical schooling was to teach how to save lives, not how to tend to their demise.” ( Being Mortal; Medicine and what matters in the end, Atul Gawande)
As my grandmother degenerates into a living mass that is completely rid of any connection with the cognitive world, my grandfather and I become nothing more than mute spectators. Leela’s coos provoked no response from her. She stared into empty space and took another labored breath. They both seemed to be on the same stage of growth, except my daughter may progressively be able to communicate her needs while my grandmother does the opposite.
She is gone, we are just carefully protecting her body.
I hope a day arrives soon, when the cure for Alzheimer's is discovered and the world is rid of this disease just as we got rid of the pox. Until then I pay respect to the science that she believed in and thankful for the wisdom they uphold.
( dedicated to the doctors who looked after me)
