Shabnam

Head held high, posture taut, prying eyes covered with proxy spectacles, legs stretched apart and hands akimbo. That was my first visual of her. As I entered the paediatric ward on the seventh floor of the hospital building, I saw her standing on the patient’s bed, enacting a teacher’s scold and an elderly staff affectionately begging her spectacles back from the little master. Seeing me enter the ward, the staff quickly snatched the spectacles back and rushed towards the nursing station, leaving her annoyed. She glanced at me with cursing looks for I had just disturbed her majestic play. The thought of an unknown figure interfering her naughty venture was certainly not welcomed.

Being the first day as registrar in the department I myself was trying to grasp the feel of the surrounding, switching my attention away from her I had a look at the ward, It was comparatively a small-sized ward with two rows of beds arranged in parallel, flanking a central aisle. There was a small nursing station separated by wooden and glass partition. A heap of ward register along with a few clumsily scattered paper bundles, the patient’s files, were lying on the blue and grey painted nursing table.

As I collected the files together, there was a gentle tap on my shoulder, I turned around and found Dr Vidu standing behind, holding Nelson’s paediatrics in her hand.

“Hi, so you have joined. Welcome aboard,” said she.

“Hi, how is the unit, seems quite nice and cosy here,” I said, to have the conversation going

“You bet, it is,” she replied before being interrupted by the naughty occupant of the bed number one, who had come running to greet Dr Vidu.

“Namaste doctor,” said the little one

“Namaste Shabnam, yeh tumhare nai doctor hai,  main to aaz se dusre ward mein jaa rahi hoon”

Vidu tried introducing me to her, however, Shabnam merely tilted her head towards me with a restrained lateral gaze wearing fake anger, twitched facial muscles and piercing vision.

“Hello Shabnam,” I greeted trying to break the ice, but she chose not to answer and fled back to her bed.

“Let’s get going,  I will start the patient over,”  said Dr Vidu.

“On bed number one here; she is Shabnam, the showstopper of our fashion walk, very naughty as you may have realised by now,” She said, on the medical side; she is eight years old Nephrotic syndrome, a little on the higher side of age for minimal change though. She is on steroids 6o mg per meter square as per ISKDC regime and at recovering.”

Nephrotic syndrome is a type of kidney disease where kidney as a filter of blood waste gets damaged and starts excreting the good protein albumin in the urine. Minimal change Nephrotic syndrome is the most common and least dangerous type of Nephrotic syndrome, responds very well to steroid therapy.

“On bed number two, he is Ramesh five years case of enteric fever………………”

After the rituals were over Vidu left bidding goodbye to Shabnam who responded in ostensibly caring fashion.

As a registrar paediatrics, my job was to examine the patients, ensure their investigation and treatment protocols as well as to present these cases to our bosses, the unit head and the associate

Even while I was busy with the nervousness of presenting cases to my superiors,  I could see at the far end of my visual field, her eyes still chasing me,  only the expression of fake anger was replaced with that of impatience, itching to talk.

As soon as the seniors left I sat down near the nursing station along with Dr Fatima my junior to discuss the post-round work with her, Shabnam came quietly and stood there.

“Namaste Shabnam,”  I took the initiative for the second time

“Namaste,”  she replied

“Dr Vidu to meri friend thi,“ said Shabnam in a low down tone.

“Main bhi ban jaunga,” said I assertively.

“Lagta to nahi hai.”

“Lagta nahi hai, kyun?”

“Aap haste to ho hi nahi,”

Subah se dekh rahin hoon munh to chadha hua hi hai aapka.”

Fatima burst out laughing

I was speechless. Speechless at her innocent and accurate observation of human behaviour.

I was always a man of few words,  for more often than not, words had betrayed me. Inability to articulate the right words at the right moment had converted many of the rights in my life into wrongs. Over the years, by default or by inactivity, the working threshold for my laughing muscles was set unusually high. What surprised me, however, was that a small girl of just about eight years had picked up this distinct behavioural anomaly on the day one of our acquaintance.

Clearing my throat and summoning my wits. all I could say was,

“Tumhare sath rahonga to jaroor shekh jaunga , achcha ab jao abhi mujhe tumahara case study karna hai.”

Turning to Fatima, I said,” what were you laughing for?”

“No, nothing  we all knew that you look a ‘khadoos‘ registrar, now the feeling is getting transmitted to the patients alas well.”

“Hilarious, now tell me about her case, Vidu told me she is minimal change,“ I asked.

“I hope so, she is too sweet to harbour any of the complicating variety,” replied Fatima with evident concern in her voice.

“What is her urine albumin status?”

“Two plus,”  came the answer as I looked up to see ‘ it was Shabnam who answered.

“You still here jao apne bed per,” I scolded.

“Tophy do to jaungi” Shabnam said.

Fatima took out a chocolate from a pocket and handed over to her as I watched helplessly

“Let’s wrap up this session.” I said, “we will discuss this in the second half.”

I left the ward wondering, why is God so unfair to these innocent children,  to have made them suffer such nasty disease?

Over the next few days Shabnam became an integral part of my otherwise mundane, ritualistic daily routine, whether it was case presentation, sample collection or taking tutorials for junior’s Shabnam was always there listening, chatting, teasing or simply making merry, she was omnipresent in my little world, confined by the boundaries of the fifth floor paediatric ward.

I became a regular chocolate buyer.

Shabnam was discharged a week later and the same day my facial muscles returned to their previous non used status.

(2)

Life of a resident in paediatrics is difficult, not only because it starts early morning five o’clock with blood collection of these tiny tots, or extracting the history from these little masters is a formidable task but also because the day never ends, the calls keep on coming, if it is not about the new patient admissions then you will be called for the dreaded intravenous lines which require to be changed at the whims and fancy of the nursing staff and your juniors. The catheters had a very peculiar habit, they always chose to go out at a time, which is mostly the time you have portioned for your sweet little sleep and if by sheer luck these catheters decides to have mercy on you some night, then on that very night one or the other infant will start crying excessively without any goddam reason, as if by design.

Even the dreams are not spared, in whatever miniature size they came because of meagre sleep time, they always depicted horrendously crying infants, kicking at your face, full strength, while you are trying to overpower them with the help of at least four assistants on the examination table to catheterize their micro-sized veins.

As a registrar, I had the additional burden of treating patients, preparing a seminar and the most fearsome of all, presenting the death stats; a place where you allow yourself to be crucified by the nailing question of other unit heads; eternal questions, how did the child succumb? Were the protocols followed?……… A verbal post mortem.

And if you still had some strength left, you were expected to study… A lot of it, actually.

Shabnam came for follow up in the OPD, once or twice over the next few weeks with her mother Ameena , who looked like the caring type, more than that I had never bothered to know. Shabnam was doing well, her urine albumin nil, that was all I cared.

It was probably towards the end of my tenure as registrar, nearing examination time, when one day while I was seeing patients in my OPD chamber, about fifty of them lined outside, waiting for their turn, a quarter hovering over me, trying to permeate all the access, I heard a slightly familiar voice, raising my eyebrows I noticed Ameena amidst the crowed.

“Kya hua ameena,” I asked her, showing concern.

“Doctor saheb aap shabnam ko dekh leejiye,”

“Kahan hai shabnam?”

“Ye rahi , yahin to hai.”

My goodness, she is Shabnam, I couldn’t believe, instead of my cheerful, chocolate friend Shabnam, there stood, a completely bloated figure, about the same height as that of hers, eyes concealed below the puffed eyelids, cheeks swollen and sagging with overweight, skin shiny, stretched, abdomen tense bulging out,” Oh my God ! Is it you Shabnam ”

“Yeh kya kiya? Dawai nahi kar rahi ho iski,” I shouted at Ameena the mother.

Then turning towards Fatima who was sitting across the table, I said.

“Take her to ward and admit her stat, today is my death stats meeting but I will come as soon as I am done here, meanwhile you start the treatment.”

Fatima quickly left the room as directed.

After the OPD was over I went to the ward to have a look at Shabnam, feeling overworked, with the relatively heavy OPD and the anxiety of presenting death stats hounding my brains, I was already irritated and the irritation was compounded seeing Shabnam in such a sorry state.

My anger and frustration broke on Ameena

“Kaisi maan ho tum?’

“Bachchi ko dekh nahi sakti, dawai nahi di hogi, aur kya?”

“Dekho kaisi halat kar di bachari ki.”

“Doctor meri ammi ko kuch nahi kahiye,” came the slow, burdened voice of Shabnam.

“Kyon, kyon na khoon, inhe tumhara khyal rakhna chaiye tha.”

“Ghar par choti ammi inse ladti raheti hain aur abbu bhi ammi ko marten hai, aap meri ammi ko kuch nahi kahenge“, replied Shabnam in a slow sobering voice.

I stood there shocked, motionless, this was the second time the girl had caught me off guard and speechless, shocked at her innocent revelation, all I could say was,

“I am sorry main tumhari ammi ko kuch nahi kahoonga. Tum aram karo main baad mein aata hoon “

Drifting my eyes away from her, I said to Fatima,

“I am going for the presentation you take care of her.”

Why is god cruel only to those who care for human feelings, nothing happens to like of her father, if only Allah gives me a chance I will slaughter that rascal

As expected Shabnam’s urinalysis revealed gross proteinuria. The reason for that was pretty clear in my mind, plain neglect. However my bosses thought differently, the duration of omission of medicines by Shabnam was little less to label her as a defaulter. It was probably a case of steroid dependence; they argued, especially keeping in mind that the last episode of proteinuria in her case was about four months ago.

I was directed to do a kidney biopsy on her

In a girl, in whom doing a simple intravenous catheterization was like taming the tigress, kidney biopsy?? Insanity at its best.

The procedure was scheduled for the next day.

Next day my prayers went into extra time, I bought two chocolates, one each for pre and post-procedure

The mission was accomplished in two hours.

Fifteen minutes for going through the investigation report–bleeding time, clotting time, prothrombin time, INR etc.

Fifteen minutes for taking informed consent, Ameena was unexpectedly cooperative and understanding

Fifteen minutes for; five in the air rehearsals with the biopsy needle,

Forty-five minutes for coaxing, luring, taming and finally grabbing and securing the tigress in restrained unmovable position by all those present in the room and by those who volunteered to help.

Ten minutes for silent, final prayer,

Five minutes for the actual procedure,

Half an hour of receiving a post-traumatic scolding from Shabnam.

Every attempt to console her went in vain. Even the five stars couldn’t do the trick and kept lying on the nursing table, uncared for.

The chocolate was still lying on the table when I returned in the evening; I took it and was rolling in between my finger and thumb when Shabnam came quietly and snatched it away from my hand

“Yeh mera hai, per aap gande doctor ho.”

“Kyon?”

“Aapne mujhe bada wala injection lagaya.”

“Aap ko theek karne ke liye hi to lagaya”

“Mujhe nahin theek hona hai “

“Chalo theek hai per mujhe to app ko theek karna hai”

“Bachcho ko theek karoonga tabhi to exam mein pass ho unga”

“To app mujhe theek kar do main appko pass kar doongi “

“Pass app thori hi kart sakte ho, pass karna to bade doctor logon ke hath mein hota hai”

“Main sab bade doctor logon ko janti hoon main aapko pass kara doongi “

“Promise!”

“Promise.”

The deal was duly registered, an elderly staff nurse as a witness.

(3)

Exams were about one and a half months away; respite a little further.

Residency examinations are probably the toughest nut to crack, second only to final MBBS examination, which to my mind have maintained their number status till date, in the chart, listing the cruellest thing any student can be subjected to.

What makes these examinations more special is that preparation are perhaps more ruthless than the actual kill. I was no exception and submitted myself, passively, willingly, without any resistance to the merciless bashing of preparation horror. One month prior to the final exams, I shifted away from the main hospital complex, to a more secluded and supposedly no disturbance zone, detached myself from the mundane habits such as chatting with friends, watching the news on television or any other forms of time-wasting tactics. My room became an old bookstore and bed looked like an out-of-order Xerox machine, half of its entire length covered with photocopies of notes and the other half reserved for ventral suspension of my tiresome self, time permitting of course. Even if I allowed myself some relaxation, I was hurriedly forced to retire back to the caged confines of the room, by the scolding and taunting eyes of any onlooker who spotted me outside.

During this one and half month I had only occasional contact with the paediatric ward, none with the world otherwise. Fatima told me Shabnam was subsequently discharged, once again Ameena was instructed to give her medicines regularly, to maintain the diary of her daily urine albumin readings once again to spare Shabnam from the ill effects of their family quarrels.

Other than this there was nothing to warrant my attention, and no excuse for wasting precious study time shall be entertained, I was told in very clear terms. I obeyed.

Theory papers were uneventful, nobody to point mistakes immediately, results are delayed so less humiliation.

I was declared lucky as the practical examinations were to be held in my own hospital. However, to me, it made matters worse. Suffering insult by an unfamiliar examiner at some unknown destination was an acceptable bargain in contrast to being humiliated in your own hospital in front of your own unit. The images of myself getting the’ examination block’ , standing in the middle of the ward, unable to answer those very questions which I taught my juniors, began haunting me day and night.

Miracles don’t happen, not everybody clears this kind of examinations, I was told. One or two major upsets are bound to happen, will I become the victim?

The day of the practical examination had an unusual beginning, the one thing which I have been doing daily, since my childhood days and every moment for the last month, could not be done, the prayers. The mind simply refused to focus, butterflies of the stomach made sitting for pooja impossible, eyes begin seeing through objects, persons and everything, as I entered the examination area, there were so many faces who were probably friends, colleague and seniors but my brain refused any form of comprehension for it was, itself entangled in the web of cases and Viva specimens.

There were to be two short cases, one long case, instrument stations… so many of them. If one can crack the long case more than half the battle is done, but it was a big if. For me, the proceedings were to start with the long case, bite the bullet straight away.

With my heart beating at an exaggerated pace, I entered the paediatric ward, unusually clean with a patient bed, examination table, work stations everything covered with milky white bedsheets but this didn’t impress me neither did it reduce the sweating on my face. Colour white represented peace or post mortem sadness. I wasn’t sure, what I was sure though was the realization that I am going to be a martyr.

Taking the step closer to my martyrdom I shifted the green patient curtain to have a look at the patient and my heart skipped the beat, as the miracle had struck, it was the Godly intervention or perhaps the God herself personified.

“Namaste doctor,” came the familiar voice

“Namaste Shabnam, tum!”

“Main aapko pass karane aayee hun”

“Thank you”, said I, as a drop of tear rolled down my face, which feel it carried; happiness, relief or thankfulness I am not very sure.

But the miracle had actually happened, as rest of the passage through the examination was more confident, more relaxed, smoother and certainly positive enough to help me clear the exam which I ultimately did.

I still remember that for the next fifteen days I didn’t bother to even peep in the ward, I had every right to relax after such a horrific one and half month.

After the period of relaxation and enjoyment was over, I returned with yet undeclared victory triumph on my face, there was nobody in the ward

Dr Fatima has gone down to the intensive care, the sister told me.

I went down to the fifth floor; the mood was light, attitude jovial, when I reached the gate of the intensive care unit, I was so engrossed in my chain of thoughts, so restless to recite the war poems that I completely failed to notice the utter silence outside the unit. Neither the bunch of curious relatives of the patients peeping through the circular glass window of the IPCU gate nor the crying eyes of Ameena could attract my attention. Filled with enthusiasm, I banged open the door only to be paused, both in thought and motion. I stood there bewildered for a few seconds when I heard Fatima’s voice.

Hi, come, your Shabnam needs you

With difficulty I focused onto the scene of action and saw Fatima along with two other housemen leaning over the patient, who looked like Shabnam, trying to establish the Intravenous line, Shabnam on the other hand lay there motionless, devoid of any pain and resistance, nostrils pronged with a thin catheter carrying oxygen, Ryle’s tube passing through the nose down to the stomach.

“Whatever happened to her?”

“Apparently both the mother and daughter were thrown out of the house, they had been staying on the streets.”

“she has been running a fever for the last three days, vomiting and abdominal distension since yesterday and loss of consciousness since today”.

“Peritonitis with septicaemia”, I said

“Yeh you are right”

Why am I right, I shouldn’t be, this isn’t exam dammit

Distraught, I stayed there, trying to do whatever I could. I spoke to seniors for possible changes in the antibiotics with no other intervention, called up pathology urging them to hurry up with the reports and ordered chest physiotherapy. All in the hope to bring her alive. Nothing happened. Fatima left after finishing her duty, I stayed with the next registrar and the next one, nothing happened.

At around two in the morning, Shabnam looked slightly better, her fever had subsided, eyes opened momentarily, and I thought she looked at me.

At four in the morning when my eyelids refused any further entry of light rays and muscle started ditching me, upon repeated request from the on-duty registrar, I decided to retire back to my room.

At five in the morning, I slept.

At two-thirty in the afternoon, my eye muscles started functioning again and I regained senses.

Immediately I called up to inquire about Shabnam.

“She is gone” Fatima informed in the saddest tone possible

“Gone, what do mean? She was better in the morning when I left.”

“She was, she didn’t expire.”

“The arrogant father came and took her along LAMA.” (Leave against medical advice)

“Such a big Rascal he was………………” Fatima’s outburst continued.

“Are you listening?” She asked after a while.

I wasn’t listening; I was apologising to my chocolate friend who had kept her part of the promise,

But I had failed miserably