The Bombay Review

Exhaustion drives a surgical resident to what many would consider criminal behavior. In a bid to avoid reprimand and unsavory consequences, Aamir convinces a homeless patient to cover for his negligence, leave a wound uncleaned for a week, and tries to make his patient disappear. This story promises to raise eyebrows and leaves the reader with some confusion about who to blame. – Shreya, The Bombay Review

            You – you, Aamir, no-not-the-movie-star-just-named-after-him, lowest person on the surgical residency totem pole, lackey of the surgical unit, drudge, grunt, lickspittle, slothful ignoramus– you, on only the twenty-second day of the first year of your surgical residency, begin this succession of screw-ups.

            You can’t claim that you didn’t know better. Even a medical student on first surgical rotation knows you have to be error-free on Monday morning rounds with your senior residents and Unit Professor: every overnight problem has to have a solution, every preoperative workup has to be complete, every wound has to be debrided, every dressing has to be done perfectly. If you fail at even one task, your senior residents lose face. And if your seniors lose face, they’ll make sure you don’t scrub in on the next several major surgeries. And if you don’t scrub in during those first few months, you’re labeled inexperienced and who wants an inexperienced first-year to assist on the “real” operations? You might as well commit to a lifetime of hernia repairs now and leave all the “real” surgeries to the “real” surgeons.

You know all this. Yet, on only the twenty-first night of your training, tired and post-call, you give in and sneak in an hour of sleep. You don’t just fall asleep, tired – you deliberately, consciously, decide that you are tired, find an empty patient bed, set an alarm for one hour on your cheap imitation black Casio wristwatch and fall into a restful sleep for that amount of time.

It hits you, of course, when you wake up in a daze to the low-key beep-beep sounds emanating from your left wrist. Your heart swells with an impending sense of doom as you mentally catalog how much is still left to do: write all your notes, incise and drain two patients with particularly pregnant abscesses, and, worst of all, debride and re-apply dressings on all the chronic wound patients under your care.

            As the early hours of morning tick-tock into dawn and you re-run your mental checklist, your desperation mounts. You have managed to scribble half-hearted notes- you’ll get into trouble for the quality later, but at least they are done. You’ve drained the two abscesses – it took up more time than you had originally budgeted for, but your seniors won’t know or care as long as the tasks are accomplished. But as the sun starts to peek from behind the tops of the century-old banyan trees outside your government-run hospital and the morning-shift nurses begin to cheerfully stream in, you realize exactly how costly that one-hour error has been: you now have less than thirty minutes to remove dressings on, debride and re-bandage five chronic wound patients. Impossible, you whisper to yourself. A feeling of irrevocable blunder makes it hard to breathe- in less than a month into your first-year training, you will have missed making the deadline for wound dressings by rounding time. Why, just one of them – Syedbhai, the homeless pavement-dwelling beggar with a massive cricket-ball size ulcer on his forearm, gooey with resistant bacterial pus – will take at least twenty minutes.

            Unless. Unless you buy yourself time by simply wrapping a fresh set of bandages over the original, and save the actual cleaning and debridement for later. (You will claim later, when you are safely a senior and able to brag in front of obsequious juniors hanging onto your every word that this was your own idea but rumors of such “shortcuts” have circulated for years). If you do it just for the worst wound, you get an extra twenty minutes to do the other wound debridments properly. And Syedbhai – homeless, family-less and grateful for a bed to sleep in – is the least likely to get you in trouble. You tell yourself that there is no real harm done here- you’ll get to it later in the day and he will be simply delayed by a few hours in getting his wound cleaned. Of course, this plan needs the patient’s active cooperation – one slip of his tongue and you will be exiled for longer than your Hindu colleagues’ favorite Lord Rama himself.

You adopt the swaggering, bullying gait of your seniors as you walk over to Syedbhai’s cot in the verandah of your ward. Your tired but healthy frame towering over him as he looks up at you, simultaneously fearful and pleased at the attention. He pauses mid-breakfast, scrawny body scrunched over the chipped plate. His head is bigger than his ribbed torso as he ingratiatingly looks up at you. You find yourself adept at persuasion that first day- telling him how you want to do a really, really good job and today’s dressing will just have to wait until later, but if he insists you will do it now. Syedbhai agrees, as he knows he must, although he manages to win an extra meal in his negotiations. You hold your breath during rounds as the group pauses at his bed but the patient doesn’t complain and neither your seniors nor your Professor ask to look at the wound.

            This could still have been a one-time mistake, a temporary blip in your efficiency. But you compound the error by letting the day pass without cleaning Syed’s wound. Procrastination always was your weakness, you were well-known as a student for turning in projects at the last minute although somehow you managed to always pull it off. Looking back, you know that afternoon was your one chance to get back on track but you passed on it. Syed reminds you, of course, but you placate him with a cup of chai and win another reprieve – this one for twelve hours, before tomorrow’s rounds. The next morning, however, a perforated appendicitis upsets the schedule and rounds are canceled- you put off wound cleaning again, now into Tuesday afternoon. A “VIP” patient’s urgent admission for an incarcerated hernia alters your day once more, and you end up putting off cleaning and again simply re-bandage the wound Wednesday morning. By Thursday you are actively avoiding Syed, sneaking him off to unnecessary X-rays right in the middle of rounds so none of your seniors see him. The long week runs into Friday, then Saturday, when he starts up with high fevers – the infected ulcer, now buried under two inches of “fresh” bandages, is likely gushing antibiotic-resistant bacteria into his bloodstream, You catch your senior resident at Syed’s bedside in the middle of the day, looking at him worryingly. He asks if you’ve been diligent in cleaning his wound through the week. Luckily for you, the exchange is in English so Syed is unable to understand. Although even if he had understood, by now he is too sick – frail body shaken by chills and rigors and drenched in sweats – to really participate in a conversation. You reply in the affirmative, obviously, but it takes all the limited acting skills you can muster to hide your panic when you’re told to prepare him for surgery “first thing Monday”.

            This is when you realize that you’ve gotten in over your head, and seek advice. The only person you can trust is another first-year, a former classmate of yours. He listens patiently, then shoots down your admittedly desperate idea of a stealth operation on Sunday. A week without wound care – you sisterfucker, there are probably maggots crawling under those layers of bandages. You swallow hard, silently cursing yourself for basically committing career suicide, imagining your parents’ reaction if you get kicked out of residency – the shame, the ignominy. Your friend offers the only way out. Get rid of him. If there’s no patient Monday morning and he didn’t die, it can’t be your fault. Patients come and go all the time. Bursts of practical advice lead to a plan. Put him on the train to the next city, he can go to the hospital there. They’re better equipped than we are, its best for him. Make sure you use a goods train, not a passenger train. The passengers will smell the infected wound and not let him on. Ask the ward boy for help, he’s done worse things for residents before. Don’t give him too much, you’ll raise his fees for all of us.

            You approach the “ward boy” – really, a balding middle-aged government employee with a paunch and a scraggly mustache, but old British terms die hard – with the plan. You are hesitant at first, but the ward boy doesn’t bat an eyelash at what you are asking him to do. He is more interested in negotiating his “fee”. He asks for two hundred and fifty rupees but, mindful of your friend’s advice, you negotiate it down to two hundred. The ward boy goes over the train schedule and the two of you settle on the train departing early Sunday morning at six o’clock – you should be out by five o’clock, when most patients and their families are asleep and there are far fewer nurses.

            The plan goes well early that Sunday. The ward boy loads Syed onto a stretcher and brings him down to a waiting rickshaw, driven by a “friend”. Another seventy-five rupees for the friend, negotiated up from fifty after the driver smells the wound, but you are too nervous to argue. You follow them on your scooter. At the railway station, the rickshaw driver and the ward boy magically procure a wheeled rusty metal stretcher, placing an uncomfortable and weakly protesting Syed onto it. You had placed another fresh bandage over the last one before you left the hospital, but the stench from his wound is nauseatingly unmistakable. You shush the patient as you walk alongside, telling him how you’re arranging for him to be transferred to a different hospital for better treatment. Syed resignedly accepts your words at face value, his sickly body shivering on the cold metal stretcher as the two men push it up the incline and onto the open air platform.

            The three of you walk alongside the stretcher toward the sloped end of the concrete platform. The rust-colored goods train is already there, carriages extending past the edge of the concrete down the tracks. You and the ward boy had planned this final step last night – deciding to place Syed in one of the half-empty goods carriages after the train starts to leave so he doesn’t scream and draw attention to himself until it’s too late. The last thing you want is for Syed to be discovered. Someone this sick would be sent right to your government hospital and, if he recovered, would he have a story to tell.

            It’s been a while since you were at the railway station but little seems to have changed.  Your gaze runs over the familiar sights as you wait for the engine driver to signal departure – the same old open tracks, large rats scurrying between them, the paan-stained walls, hawkers selling chai to early morning travelers. The television sets appear new – large, dusty sets enclosed in rusted black cages, hanging from the ceiling along the length of the platform. Just as you hear the clocks chime six, the screen closest to you flickers to life. In most public spaces, morning programming is confined to classical morning raagas, but the railway employee running the show this morning seems to have other ideas. Madhuri Dixit’s ethereal beauty graces the soot-smudged screen as the familiar opening tremolo from her hit new song Mera dil bhi kitna paagal hai, my heart is so mad interrupts the quietness of daybreak. The stretcher comes to a complete halt, as all three of you look upward, transfixed watching the disabled poet played by Sanjay Dutt limp on crutches next to Madhuri in the morning mists of the Himalayan foothills. Too shy to tell her character how much he loves her, wishing she knew him to be the anonymous poet whose verses she adores and sings. My heart is so mad, even as it loves you, Sanjay Dutt mouths, whenever you come in front of me, it fears to tell the truth. Even Syed feebly props himself up on the stretcher with his rigoring good arm to get a better look, empathizing with the handicapped hero silently in love with the heroine the whole country is in love with. No matter how much I tell my heart, no matter how much I try to make it understand, it’s naïve, it’s innocent, it doesn’t comprehend, all day and night it sighs in anguish…

            The horn from the engine rudely interrupts the music as the train driver signals pedestrians and hawkers to clear the tracks. Slowly, majestically, ponderously, the carriages start to roll forward. The rhythmic clanking of metal wheels on metal tracks is your starting whistle. You nod quickly at the ward boy and the rickshaw driver. The three of you get the stretcher rolling down the slope at the end of the platform, parallel to the slow-moving carriages on the tracks just as Syed finally realizes what is going on and opens his mouth to protest. Ignoring his cries for help, you grab Syed by the shoulders while the ward boy yanks him up by his feet and the rickshaw driver keeps the stretcher moving – a makeshift relay team of sorts. You swing his body between the three of you, picking up momentum with each swing, getting ready to launch him through the half-open side-door of the carriage.

It’s only the twenty-eighth day of the first year of your surgical residency and, yes, you have screwed up, but you didn’t get this far by accident – you are smart, you are resourceful, you are hard-working, and by God you will fix this procrastination problem right now.

Alok is a physician currently based in Cleveland, Ohio, USA  but originally from Gujarat, India. His prior narrative works have been published in Bellevue Literary Review, Annals of Internal Medicine and Health Affairs, anthologized in Narrative Matters and included in the Best American Medical Writing 2009.