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The Cause of Death

It was 8.45 am on a Thursday morning and I slipped into the ER hoping no one would notice. I had left the previous night at 2.30 am ,just like I had every other day for the last 15 days of my ER posting but that never seemed to matter to anyone. I saw my colleague already attending to patients and breathed a sigh of relief. He smiled as I said Hi. We were good friends but for the last 2 weeks I had begun to loathe him. His efficiency , sharpness, intelligence , all traits I thought I possessed too but this posting had made me question . I wondered how he was coping so well while I crumbled physically , mentally ,emotionally …. I entered the doctor’s room to find my junior looking like a zombie and felt better instantly.

There’s a strange sense of relief in collective misery. Hey didn’t you leave early yesterday , I saw you leave at 1.30 ? I said almost sounding condescending . He gave me a dirty look as I took a sip out of his coffee. I decided I needed a stiffer dose of caffeine to get through the day . Thursday’s were the worst , my eyelids were fighting to stay open , my legs felt like wood ,my REM sleep deprived brain couldn’t tell the difference between a J point elevation and STEMI and Sunday was a good 3 days away. ER posting was like combat training, it made you resilient ,taught you to function against all odds ,or so I had been told by my seniors . I was hoping someday in the future I could say the same to some junior who was burning out , but right now it just didn’t make sense. I wasn’t learning , I wasn’t saving lives , I was barely surviving.

He came in or rather was brought in on a trolley at 11 am . He looked young ,early twenties I thought , with a lean muscular build that indicated hard manual labour . He was lying motionless with drooping eyelids . He was intubated and put on bag and mask ventilation and his diagnosis was fortunately clear even to my otherwise foggy brain. He was accompanied by three people , a thin young lady with a toddler, probably his wife who looked like a child herself and a young man wearing an ill fitted shirt and trousers. “ Saanp kata” I asked and they nodded . I found the referral notes from the district hospital “ASV given ,referred to higher centre for ventilatory support”. I laughed in my mind as I read ventilatory support, there were 10 other patients in ER right now in need of a ventilator , many more in other parts of the hospital, ventilators were always full and even the peripheral hospital knew it.

In the absence of a ventilator , I probably couldn’t manage him better than the hospital who had referred him. But this was how it was and there was nothing one could do about it. The wall Oxgen ports were already full , but the nurses ingeniously divided one source between two patients using a T piece . The oxygen concentration was probably just as much as room air . I told them “machine toh nahin hain abhi, dekhte hain”. I taught her how to bag “ek, do , teen,char dabao, sahi se karna hain ,iski saas ruk gayi hain, theek se karogi kal thak theek ho jayega” . I wondered if she understood but I never stopped to check , the next patient had already come in…

It was 3.00 Pm and the man and the toddler were nowhere to be seen . “Ghar gaya hai paise lene” she said and I nodded . His saturation on my pulse oximeter was 95% . I asked him to raise his hand ,he tried but was still weak . I moved on to my next patient without any further discussion. 
My junior from the ER ward came in and announced one free ventilator as me and my colleague competed for it. His young male with pneumonia versus my snake bite , we didn’t bother thinking about the others who required ventilation. We had our own set of rules about who deserved a ventilator ,whose life was more valuable than the others. No we didn’t want to play God,but there wasn’t any other way. Young over old, acute over chronic illness, previously healthy over multiple comorbidities, salvageable over too far gone, We did it everday without any regret . We had to triage. So a 65 year old diabetic , hypertensive with renal failure with Acute respiratory distress in shock , unlikely . I sometimes shuddered thinking how both my parents were diabetic , hypertensive and silently thanked god for better resources. So that day the young male with pneumonia got the ventilator . “Yeh to snake bite hain Ma’am , ASV diya hain, ambu pe theek ho jayega” my junior said and I couldn’t contest it.

I got on with my work. ARDS, scrub typhus, Heart attack, stroke, fever with shock , chronic liver disease with upper GI bleed all fighting for a chance to live .Soaked in their secretions , with multiple tubes inside them , lying on an cold hard metal trolley, but my overworked ,desensitized brain had stopped feeling . When it did, the reality seemed too painful. I couldn’t save them , but didn’t they deserve a dignified death ? I had decided to block my thoughts a long time ago. 

It was 11 pm , I saw the child wife from the corner of my eye as she continued to bag him. Her eyes had begun to droop . I wondered where the other man was .As I started walking towards her, someone screamed “intubation” . A patient had a cardiac arrest and the nurse called for help. I jumped on the trolley and started CPR and was soon joined by my junior . I left him with this patient and dismissively told him “declare him after 15 minutes if he doesn’t revive” and walked off to complete my notes. I had to finish my work and get atleast 5 hours of sleep , I had to last two more days.
At 1.00 am I was ready to give a hand over to my senior resident when my thoughts went back to the child wife and I decided to check on the snake bite patient.

My super efficient colleague had already begun his handover and would be done before me as usual. As I went closer to his trolley, I saw her head resting on the trolley. She had fallen asleep and he lie there limp and listless. I woke her up in panic and called the staff for help but it was simply too late . I shook my head to indicate he was no more . She looked at me in quiet acceptance , her eyes brimming with tears. I don’t know if she realized what had happened. I hoped that her ignorance would shield her from the harsh reality. 
My junior was preparing the death certificate . He screamed “cause of death Ma’am?”

I pondered over the causes , poverty and illiteracy that made him vulnerable to this cruel act of nature ,the collapsing primary and secondary health care system which forced him to come miles away in the hope of better treatment , the tertiary care government hospital bursting at its seams with no adequate infrastructure or manpower , yet forced to keep its doors open for everyone, the burnt out ER resident who had more on her plate than she could handle , lack of social/family support , the child wife who let fatigue get the better of her or simply his karma which I had come to believe in the ER………………….. I told him ,
Cause of death : Type 2 Respiratory Failure
Neuroparalytic snake bite.