Alok A. Khorana
For the first time that night, Vivek was actually sitting down—his tall, lanky figure hunched over the only desk in the center of the ward. He was done with all the tasks for the day and ready, finally, to get started on his stack of paperwork—mostly progress notes and orders needed for the next morning. It was nearly midnight, and the daytime hubbub of the government hospital had subsided to a quiet hush. There was a gentle summer breeze, and the rustling of the leaves of the banyan tree in the courtyard could only be heard upon careful straining. Most of the patients were asleep, their beds arranged in three long rows in the cavernous ward. The night-shift orderlies had retreated to their various corners where they would spend the rest of the night gossiping in low voices and smoking bidis. Even the patients’ family members, usually a raucous bunch, had quieted for the night.
As a first-year resident, Vivek was both at the bottom and at the top of the hospital hierarchy. In the pecking order of physicians, Vivek was the lowest of the low—the grunt, the lackey—subject to daily abuse and capricious insults during rounds by his senior resident Ajay, or by any senior resident on any unit. But in the little world that was Ward 10, Vivek was the doctor. He was the one who decided which patients got a real bed and which had to sleep on the floor. He was the one who determined which patients would be treated from the limited supply of free medicines either through the hospital pharmacy or from Vivek’s personal supply, and which patients would have to fend for themselves. Responsibility came naturally to Vivek—he had learned as a child to be the mediator between his cruelly warring, alcoholic parents. He prided himself on bringing order to chaos. Lowly intern that he was, Vivek was the face of Ward 10.
Vivek was scribbling furiously with his left hand, while his right hand absentmindedly played with a curly lock of dark hair that had fallen onto his perspiring forehead. It had been a busy evening of admissions—a foot-high stack of charts stood untouched in front of him. He looked up with some irritation as he sensed the night-shift nurse, Ashaben, approaching his desk. Ashaben was in her late fifties—a bustling, dark-skinned matron with silver streaks in her hair adding to her gravitas. She had been a government nurse for decades and could tell juicy stories about every physician who worked at the hospital—dating back to their earliest training days.
“Hello, Vivekbhai!” she said, in an especially ebullient tone. “How is life these days?”
Vivek shuddered. He recognized from her tone where this conversation was going. It was the story of the month for the ward staff, and he, unfortunately, was the star. Over the past few weeks, a secret admirer had left two messages for Vivek. The first was a drawing of a heart-and-arrow left on his desk. The second was a handwritten romantic poem, inserted between a set of laboratory results. Both came in pink envelopes, and both were signed “ILU.” Even Vivek, who hadn’t seen a movie in what seemed like forever, knew Ilu Ilu, the hit song that played nonstop on the patients’ radios. “What is Ilu Ilu? What does Ilu mean? ILU means I Love yoU” So went the refrain over and over and over. Vivek despised the song, but his secret admirer—the ward staff were betting on a certain female medical student who had recently finished a rotation on Ward 10—clearly found it to be a romantic inspiration.
Ashaben sat down across from him, grinning from ear to ear. “How is our movie star doctor’s fan mail coming along?”
“No more messages, thankfully,” Vivek replied.
Although he was embarrassed by the juvenilia of the love notes and the Bollywood romanticism, Vivek was secretly flattered. He had never thought of himself as particularly attractive, but the past few mornings he caught himself looking in the mirror for a few seconds longer, wondering exactly what it was about him that this girl found so alluring.
Ashaben leaned across the desk. “You know, you’re not the only one with a love life,” she said in a sly whisper. “Ajaybhai, your senior resident…”
This next piece of gossip would have to wait; the conversation was interrupted by the entry of Aakash and Pritesh, residents from Ward 9 across the hall. Aakash and Pritesh were an odd couple: Aakash tall, heavy-set, and bearded, with perpetually tousled long hair, Pritesh short, skinny, and always anxious, with hair hacked so short Vivek sometimes wondered if he got it cut by the same sidewalk-dwelling barber that all the patients’ family members went to.
Like Vivek, they were first-years, and the three often worked together writing case histories or assisting each other with minor procedures. Tonight, Aakash and Pritesh appeared even more harried than one might expect for being on call.
“We have a cerebral,” Pritesh blurted out before he even got to the desk, referring to a case of cerebral malaria.
This diagnosis, although less common than the standard malaria case, was not quite that unusual, so Vivek didn’t reply, but waited patiently for the rest of the story.
“He looks awful. He might be in DIC,” Aakash added.
Disseminated intravascular coagulation was a rare but serious complication of cerebral malaria. The widespread activation of blood clotting pathways had the potential to compromise multiple organs. This was serious stuff, and Vivek began to better understand their sense of urgency.
“Plus he’s police or border security or something,” added Pritesh with a note of panic in his voice, “and the rest of his platoon or brigade or whatever they’re called is camped outside. His officer is threatening consequences if something goes wrong.”
Vivek said nothing, but his gaze flicked anxiously over their shoulders to the shared hallway between Wards 9 and 10 as men in uniform traipsed in and out imperiously. He, like all the trainee doctors, had heard stories of unruly mobs beating up physicians when things didn’t go well with a loved one and based on what he had heard so far, things did not appear to be going well.
“We think he’s throwing clots to his legs,” Aakash added, apprehensively pulling on his beard. “His left leg is cold and blue.”
Vivek asked the obvious question: “Where’s your senior?”
“That’s the problem,” Pritesh answered, almost screeching in distress. “He signed out to your senior.”
“And Ajay won’t answer his phone,” Aakash said. “We tried to page him, but the orderly can’t find him.” The paging system in the government hospital consisted of bribing an orderly with a cup of masala chai to go up to the resident’s hostel room and knock on the door.
“Perhaps he is with his mashooqa,” giggled the eavesdropping Ashaben, slipping in the Urdu word for sweetheart. The night-shift nurse would seize any opportunity to direct the conversation back to gossip.
Vivek ignored her comment, although he made a mental note to ask her later for details.
“I have no idea where Ajay is,” he admitted.
“Sisterfucker!” Aakash swore quietly under his breath.
Ashaben managed to raise her eyebrows archly and simultaneously pretend she hadn’t heard Aakash’s last comment. She sidled over to the far row of beds to begin her nursing rounds.
Vivek knew his panicked friends needed someone to do something. He pushed his charts away from him and strode to the lone bookshelf in the back room that doubled as an office, with Aakash and Pritesh close on his heels. Vivek pulled out a raggedy older edition of a textbook of infectious diseases, thumbing expertly through the index until he found the section on cerebral malaria. The three first-years crowded together and pored over the scant paragraphs on malaria-associated DIC. The outcomes were grim.
If this were a fully staffed hospital, the patient would be transferred to an intensive care unit, with a team of specialized physicians and nurses. But this was a government hospital. The only two intensive care unit beds were perpetually occupied. As for expertise, all they had was a senior resident who might or might not know what to do and who, in any case, was currently unavailable. Sure, the professor in charge of their unit lived in the adjoining subsidized housing campus—created, it must be said, precisely for a situation like this – but she was under no circumstances to be approached, or she would find out that Ajay was missing. There was no faster way to commit career suicide than to betray your senior resident.
So it fell on the first-years to figure things out. The textbook approaches were limited: anti-malarials plus the blood thinner, heparin. The hospital had run out of heparin at the beginning of the year, and there was no money left in the budget to purchase more until the following year. The patient was already on anti-malarials. As Vivek, Aakash, and Pritesh reviewed their limited options, their conversation was interrupted by wailing and crying from across the hall—the family members of the cerebral malaria patient had obviously arrived. Quickly, the three agreed on a plan: Aakash and Pritesh would return to Ward 9 and intensify the dosing of the anti-malarials. Vivek was assigned to find his resident Ajay. This, Vivek thought, would require getting Ashaben to talk.
Vivek found the night nurse in the second row of beds in Ward 10, admonishing one of the patient families on their dietary choices. The cerebral malaria case was urgent, but Vivek knew the only way to get Ashaben to open up was to butter her up with small talk. Ashaben had been genuinely offended by Aakash’s coarse language, so Vivek had to spend some time commiserating with her over the decline in politeness amongst today’s young doctors. Eventually her desire to gossip got the better of her and she circled back to Ajay.
“I hear he’s in love,” she said, gathering up bottles of medicines to dispense for her night-time rounds, and walking with Vivek back to the desk.
Vivek snorted in disbelief. Ajay—ever-pragmatic, so focused on building a lucrative private practice once he got out of residency—was the least likely person to ever fall in love. And it was common knowledge on the ward that his parents had arranged for his engagement to a wealthy girl from his ancestral village. Vivek was growing impatient—there was a cerebral next door, managed by two desperate first-years, going off the rails like one of those malfunctioning trains always featured in the local papers. He needed to track down Ajay, but Ashaben parceled out one morsel of information at a time.
“Well, the girl is beautiful…and smart.” The wailing across the hall grew louder, and Ashaben had to raise her voice. “So beautiful. So smart. Who can blame him?”
This didn’t sound like anyone he knew. Well, except for…his gaze suddenly met Ashaben’s, who was nodding her head eagerly, her face smiling, almost willing Vivek to guess the name. It finally dawned on Vivek why Ashaben had used the Urdu word for sweetheart instead of the more typical Hindi. Not because she was trying to be filmi, but because she was referring to—Vivek still couldn’t quite believe it—a Muslim girl.
The grin on Ashaben’s face blossomed into a self-satisfied smirk. Despite his determination not to be distracted by ward gossip, Vivek’s mouth was agape. Ashaben had outdone herself. Rukhsana was in fact, a beautiful and smart medical resident on Ward 7. She was also married. And she was Muslim. In a world where arranged marriages were the norm, dating barely accepted, extra-marital affairs nearly non-existent, and inter-religious relationships unheard of—this could be the scandal of the decade. No wonder Ajay had been so discreet.
Vivek was about to respond, but the commotion across the hall in the other ward grew louder and more urgent. Voices were being raised in anger and a few choice swear words carried over, causing Ashaben to shudder in quiet revulsion. Vivek looked up to see Aakash and Pritesh walking briskly towards them, deftly evading a group of angry, uniformed men in the hallway joining the two wards.
Vivek shook his head as the two drew near, a look of desperation on their faces. “No, I couldn’t get hold of Ajay…” he replied to the unasked question. Vivek glanced over at Ashaben, who discreetly withdrew from the group, mumbling something about having to hand out medications. The two other first-years hunched over the desk in response to Vivek’s furtive motions. Vivek looked around to ensure there were no eavesdroppers, then relayed what he had just learned in a dramatic whisper. “Ajay…” he paused for effect. “He’s…fucking…Rukhsana!”
“Motherfucker!” Aakash’s response contained equal parts astonishment and admiration.
“But, wait, that means…we won’t find him tonight, right?” asked Pritesh, both practical and panicked.
Vivek shook his head regretfully. On any other night, this deliciously wicked information would occupy their thoughts and conversations for days and weeks. But there was a dying patient in Ward 9, and, worse, a potentially murderous gaggle of armed friends and family members. And no help was forthcoming.
Vivek scoured his mind, trying to think of alternative options to help his friends out. He had to admit that he had nothing to offer. His hapless gaze met theirs, and he said nothing.
Aakash and Pritesh looked at each other nervously, both swallowing hard as if a decision had been made for them. “We’ve been talking,” Aakash said in a hushed voice, looked around to make sure Ashaben was out of earshot. “How many vials of potassium chloride do you have?”
“Potassium chloride?” Vivek was puzzled. Every competent resident had their own supply of urgent medications stashed away for whatever unforeseen situation might arise with a patient who could not afford drugs, but his fatigued mind wasn’t quite connecting the circumstance before them with the contents of his secret stash.
“Yes, yes, yes, potassium,” Pritesh whispered frantically. “If we infuse it slowly, they won’t connect it to us.” Vivek looked from Pritesh to Aakash, still confused. “The cardiac arrest will come from the hyperkalemia”—Pritesh used the technical term for elevated potassium levels in the blood, partly from habit, partly to foil anyone listening to their conversations—“but it can’t be right after we administer it, or they’ll get suspicious.”
Aakash took up the conversation. “So we thought, how about we inject it into the Ringer’s solution we’ve been giving him all day? You know, into the next bag, before the nurse replaces the old one?”
Vivek blinked slowly, as the import of the conversation slowly sank into him. He opened his mouth to reply, but Aakash cut him off. “I mean, we can’t go on like this! He’s clotting off his other leg now and going into renal failure.” Aakash’s fingers were tapping drumbeats nervously on the desk “His screams are terrible, the wife and her sister are howling, the guards look like they want to beat us up…”
“If he has a cardiac arrest, they can’t blame us, right?” Pritesh said. He was rocking back and forth, his body quivering with anxiety. “Heart attacks happen all the time, right?”
“If he dies from a heart attack, then it’s not really our fault, right?” Aakash added defensively. “Anyway, you must have some potassium? We already put all the vials we had into the next Ringer’s bag, but we don’t know if it’s enough.”
As urgently as they had started the duo ran out of steam and simply stared plaintively at Vivek. The sudden silence weighted the space between them, almost as if what had been both said and left unsaid hung unmoored in the air, needing support.
A cascade of opposing thoughts and arguments whirled around in Vivek’s mind, rushing to the tip of his tongue, preventing him from speaking. Were they really going to do this? Vivek sensed the plan had just come into being, at some point during the trips back and forth between Wards 9 and 10, when the impossibility of finding Ajay became clear, or maybe even earlier, when the patient failed to respond to the anti-malarials, or when Ajay decided to disappear without having someone cover his call.
Vivek’s throat seemed to grow more parched with each layer of logic. The patient was as good as dead. Aakash and Pritesh were going to do what they were going to do. It might minimize the patient’s suffering. It might minimize the doctors’ suffering. And Vivek had no other solution to offer. There was no other solution. This was no one’s fault. Except maybe the system’s. The government’s.
That there were other, harsher, truer words—cowardice, euthanasia, murder—that could better describe what they were doing went unacknowledged then, or later.
In the end, Vivek did not speak at all. He slowly opened his desk drawer, pulled out a key, and unlocked the small cupboard next to his desk. His hands reached deep into one of the middle shelves, and he brought out a cardboard box with a green label. Pritesh nearly pounced on the box as he grabbed two handfuls of the vials marked potassium chloride, looking up just once to make sure Ashaben wasn’t watching. He handed half to Aakash, and they both stuffed them deep into the pockets of their white coats.
Vivek’s gaze followed them as they left Ward 10 and navigated through the hostile group of family and friends of the ailing border guard, their hands hidden in their coat pockets, sweaty palms grasping the life-saving, life-taking vials, until the two rounded the corner and disappeared from his sight.
Vivek returned to his desk and sat down. He still had work to do. Ajay would show no mercy in the morning if Vivek’s notes weren’t completed in time for rounds; saving the senior from being caught missing while on call was an expectation of a first-year’s responsibilities, not an excuse for incomplete work. Vivek uncapped his pen and set to work.
He methodically attacked the pile of charts in front of him, writing out his progress notes, finalizing laboratory orders, updating the medication lists to prepare for rounds in a few hours. Ashaben had gotten busy too, handing out night-time doses and dealing with recalcitrant patients and their family members, and he barely saw her as the night crept on.
As Vivek labored at his desk, he could hear the turmoil escalate in Ward 9 and the shared courtyard outside—jeeps and motorcycles arriving, the sounds of slippers shuffling as more people joined the group, ever louder sobs, whimpers, howls and shouts. An hour and a half into his note-writing, the babel of voices reached a crescendo until the summer night was pierced by singular screams of grief and agony. It was the familiar sound of a new widow entering an unfamiliar world.
Vivek knew the only way to get work done as a first-year was to stay focused and keep slogging away. He had to make up for all the lost time from the various distractions of the evening. He doggedly plowed through chart after chart, and it was close to 4:00 am when he arrived at the final chart in his pile. Despite everything, he would finish his work before the sun rose and maybe even sneak in an hour or two of sleep. Vivek allowed himself to feel a sense of satisfaction. By now, the commotion next door and outside in the courtyard had subsided. Over the past two hours, Vivek had heard the terms “cardiac arrest,” and “heart attack” mentioned repeatedly outside in the hallway, from family members and the border guard’s commanding officers and even by the patients and orderlies in his own ward. The technicality of the terms seemed to lend an aura of inevitability to the night’s events. The anger amongst the patient’s relatives seemed to have dissipated, replaced by grief—what, after all, could the doctors have done if the patient’s own heart gave out?
The plan had worked after all, Vivek thought to himself, and that too should give him some satisfaction, should it not?
As he wearily lifted the final chart to begin his last notes, the bright pink envelope underneath came into view, his first name written neatly on it, in the now-familiar cursive. His gaze went instinctively to the far end of the ward where Ashaben stood, grinning, her white teeth gleaming in the dark. She must have known all along, he thought, as he ripped the envelope open and slid the greeting card out. There was no missing the big red heart in front and the flowery script in gold font underneath. Vivek could feel himself flush with embarrassment, his exhaustion forgotten in the moment, a peculiar thrill coursing through his body.
As he opened the card, the melody for Ilu Ilu rang out. The sound took Vivek by surprise—a musical card!—and in his weary state it took several moments for this to register. The tune played for a few long seconds, the sound reaching out to the farthest beds on the ward, causing a few patients to stir in their sleep. Realizing this, Vivek abruptly snapped the card shut, and silence reclaimed the night.