The Lighthouse in a Black Hole of Calcutta

Just a little bit after high noon under the Calcutta sun, the Irish woman was telling me (a South Indian desi who has never been close to being sunburned) that I was looking pale.

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4AM.  Wake-up call.  The rough and unwelcome ring rousts me from the first comfortable sleep I have had in 8 days. I have had a busy and challenging week of cornea transplants and surgical skills transfer in rural Haldia (pictures here) as a volunteer on an ORBIS mission.  I am exhausted and rather enjoying the creature comforts of a nice room at the ITC Sonar, a treat for our last night in India. I really do not want to get up, but have promised my new friend (and ophthalmic surgical nurse) Ann-Marie that I will go with her to Mother Theresa House at 540AM. Plus, by waking up this early, I can catch up with Friday afternoon email back in Utah before all my colleagues leave work for a gorgeous fall weekend back in Salt Lake.

6AM. We get to Mother Theresa House and attend Mass. Although I am Hindu, the service is nonetheless moving in its beauty, humility, and simplicity. The melodious chorus of the nuns is soothing against the raucous boulevard outside. After mass, we stop briefly at Mother Theresa’s tomb, and then make our way downstairs to the assembly area, where we have a small banana (one of those nice baby tropical bananas) and tea for breakfast. I see a posted prayer entitled, “in preparation for going to the Apostolate.” It asks the Lord for “skill in my hands, clear vision for my mind, and singleness of purpose.”  I think to myself – how similar to the silent prayers of many a surgeon before any case, and how similar to some verses in the Bhagavad Gita. Ann-Marie and I trade personal backgrounds; she is originally from Boyle in Ireland but now works in Cardiff in Britain to be close to her children and grandson. After we all have tea, the sister in charge of volunteers arrives.  She assigns us to a team of 10 volunteers headed to the Kolaghat. Our group includes a French couple on honeymoon, some Korean and Japanese tourists, a Romanian backpacker, and some college students from hither and yon. After a harrowing 20 minute bus ride on a rickety vehicle straight out of your favorite Africa movie with exposed floorboards and a ramshackle roof, we reach our stop. We walk up the street and promptly get lost.  There are so many beautiful colors amid the squalor. As an outsider looking in, I am struck by how the people seem happy despite grinding poverty and oppressive heat. A friendly tea house shopkeeper directs us to the right street and after a 40 minute walk, we arrive drenched and tired to the Nirmal Hriday (the Mother Theresa Home for the Dying and Destitute), where the local sisters and staff engage us in their normal morning schedule.

9AM. First job is washing laundry (mostly green-colored sheets and pillow covers).  I have no idea if I am any good at soaping, rubbing, and washing the sheets and clothes, but guess that I am probably not, as they send me upstairs within 10 minutes).  Dejected at my evident lack of skill with hand-washing, I dedicate the next hour to rooftop clothesline duty, and get drenched in sweat again. Arranging the laundry carefully to optimize rooftop clothesline space and stabilize the hangings makes me appreciate what my mom did when we were little kids. And seeing the neighborhood from above is a treat reminiscent of childhood summers with relatives in India.

We have a short break for tea and biscuits, and peruse the history and teachings of Mother Theresa, who moved to India in 1937 and founded the Missionaries of Charity in 1953. After break, we go downstairs, and turn over the male and female open wards (each with about 50 beds). Clean beds, sheets, pillows, and pillowcases. Now I understand the relevance of laundry duty.  Despite all the filth outside, this place is kept in tip-top and immaculate shape.

11AM.   An agitated woman is brought in by wheelchair by Tamara, a Mexican physiotherapist who found her lying at the station. She is whisked to the female ward. After helping a different elderly woman walk to the bathroom, Ann-Marie goes to peel eggs in the kitchen.  The French husband on honeymoon holds the hand of an emaciated man on IV fluids. I look around for a little bit, noticing an unnerving sign on a cabinet (Dead Body Clothes), a medicine cabinet with an odd assortment of medications, and a sign that says “This place is not a hospital, but rather a place where the dying and destitute can go for comfort and dignity.” 

Anne Marie comes down from the kitchen, and we chat for a little bit. One of the sisters asks if I am from India (I am the only Indian in the volunteer group that morning), and I let her know I was born in Vellore, but live in the US.  The sister moves on about her work, and then a few minutes later, finds me and asks me to go to the female ward, as the woman Tamara brought in is now unconscious. I go the female ward, but one of the attendants shoos me away, “no males here!” Ann-Marie, who has not raised her voice the whole week, counters, ”We need him, he’s a doctor.” Upon coming to the bedside, I am startled by an awful sight. This tiny, poor old woman is in acute respiratory distress, not responsive, foaming at the mouth, and struggling to breathe.  Tamara is crying and asks if the woman is going to die; I don’t want to answer that. I ask the head sister if we can transfer to a hospital; she says there is no such option. One of the sisters (Sister Adriana) has managed to put a nasogastric tube in, which is starting to remove kerosene from the poor lady’s stomach. Presumably she swallowed the kerosene in an attempt to kill herself. Her pulse is fast but thready. Listening to her chest reveals a lot of “junky breath sounds”, a racing heartbeat, and a fairly loud systolic murmur (I wonder if she has aortic stenosis).  I ask Ann-Marie to see if the staff can get suction (her British-Irish accent is much more understandable to the sisters than my thick American one), and she begins suction with resolve and grit.  The sisters ask how long they should keep irrigating the stomach, and having never dealt with kerosene before, I tell them to keep irrigating until clear, normal-smelling liquid comes back. I ask for activated charcoal but there is none.  Proceeding with the examination, I see that her pupils are small and non-reactive, and the sister informs me that the patient’s fingerstick shows a blood sugar of over 300. Crap. Not only are we fighting kerosene poisoning, this poor lady probably also has DKA (diabetic ketoacidosis).    I have to get an IV started, but haven’t done one in 16 years, let alone on a dehydrated patient in a poorly lit room in a crisis.  I find an antecubital vein in her right arm, and am handed the butterfly needle, tourniquet, and alcohol cotton ball. I put on gloves but they don’t fit and are the yucky, slippery, polyvinyl kind.  I position the needle, and before piercing skin, pray to God to please let me get this stick. Flash of blood in the cannula – thank goodness! I get the IV taped up and call for saline (the sisters ask whether it should be NS or DNS; this lady does not need any more sugar, so NS it is) and 10 units of insulin. “How much volume of insulin in a 1 cc syringe?”  Fortunately, just 2 days earlier in Haldia, I saw that an insulin syringe of 40 units corresponded to 1 cc, so that makes it easy to figure out the dose.  I listen to her lungs again, and she sounds better after suction but has probably aspirated stomach contents into her lungs.  Are there any antibiotics? Sister Adriana takes me back to the medicine room, and I am looking for a 3^rd generation cephalosporin and clindamycin (to cover Gram negatives, upper respiratory flora, and anaerobes).  I search in the drawers – amikacin, nope, don’t need to risk kidney failure in this lady with DKA.  Sulbactam, nope, not powerful enough.  Ertapenem and piperacillin – totally awesome broad-spectrum antibiotics but probably overkill and don’t want to tempt resistance germinating to these “gorillacillins” in a Calcutta slum. Sister Adriana comes back – “ok, doctor, what antibiotics should we give?”  I find a cephalosporin drawer – great, but wait – cefotaxime, cefazolin, cefirizine, cefaperazone, ceftriaxone, cefipime, cefixime …Goodness gracious, why do cephalosporins all have to sound the same and why did they have to make so many new ones since I memorized the first 3 generations of them in pharmacology 20 years ago?! Ceftazidime – found it! – covers Gram negatives and Pseudomonas (which can cause a really nasty pneumonia) and Amoxicillin/clavulunate – a reasonable choice to cover oral anaerobes and upper respiratory flora.   I let Sister Adriana how often to give each one and go back to the bedside. I ask Tamara for a smartphone, and luckily one of the Koreans has a working internet connection.  After a little fumbling to get an English language interface, googling kerosene poisoning reveals that milk can be used to try to neutralize it (via the nasogastric tube).  Sister Adriana asks if we could put egg along with the milk, and pondering it, I remember that egg white has albumin, which is a molecular sponge, binding almost everything. Sure, I say, milk and egg it is.

As the staff readies the milk-and-egg concoction, the patient soils herself. The sisters and Ann-Marie change the sheets, and Ann-Marie expertly inserts a Foley catheter, draining normal-looking urine (a good sign).  However, in the jostling, the IV comes out of her vein.  I try her left hand with no success.  Sister Adriana tries her right elbow again and then her right forearm. No luck. I try her left upper arm, and get the welcome flash of blood, but then the needle slips from my finger and I lose the vein.  I begin to spy the patient’s external jugular vein, but Adriana tries the patient’s right hand and is successful – whew!. I take my gloves off; looking down at my hands, they have never been clammier.

12PM. Our patient is breathing more comfortably and looks better; she is starting to blink and move her eyes a little.  The sisters ask if we can stay for the afternoon; unfortunately we both have planes to catch. After leaving recommendations on fluids and antibiotics with Sister Adriana, and hugs and thanks all around, Ann-Marie and I walk back into the slum to hail a cab.  Ann-Marie tells me that she did not think the patient would last the hour and that I should be proud;  I tell her I am just relieved at how things turned out and grateful that Tamara, Sister Adriana, and Ann-Marie were all there with the patient at the same time.  It was only by grace of providence that a physiotherapist from Mexico, a medically self-taught nun, an Irish nurse, and an Indian-American eye surgeon crossed paths with a poor woman in pain on a Saturday morning in Calcutta.

While outwardly I tried to project calm, I had been terrified the whole time that this poor woman was going to die in front of us because her doctor was an ophthalmologist who had not taken care of general patients for 12 years.  Ann-Marie has been a nurse for 43 years, and I a doctor for 18; it is reassuring that my mentors were right - the time spent learning general medicine was not wasted, for our skills and memories decades past are still there, ready and useful. My hands are trembling, and Ann-Marie says that I look pale.  She says lunch is on her.  Getting back to the hotel, I have a nice long hot shower after the morning’s drama, and enjoyed the first good water pressure in a week. I put on my scrubs for the flight home, and ironically realize I should have put them on when I woke up that morning.

Suicide is an irredeemable sin in both Catholicism and Hinduism, and even though I worry about all the potential complications of kerosene ingestion, hopefully we have given our patient a chance at redemption, and in so doing, redeemed, in some small way, our own existence in a fallen world. For service is the rent we pay for living. The Sanskrit saying “Manava Seva, Madhava Seva”  parallels Christ’s admonition that “whatever you do unto the least of my brothers and sisters, you do unto me.” The Grim Reaper and God were both in that ward that morning, and hopefully we bought some time for our lady’s body and psyche to mend.   The morning evoked the exchange between Katsumoto and Cpt. Algren in The Last Samurai, “Do you think a man can change his destiny?” “I think a man does what he can, until his destiny reveals itself.”

The Mother Theresa Home is a lighthouse in a modern-day black hole of dashed dreams (villagers seek opportunity in the big city but often are stranded in the slum; the original Black Hole of Calcutta was a dungeon). Together, the sisters and staff offer a beacon of hope that helps wounded souls to heal.  Along with images from Mother Theresa’s life, the centerpiece of the home is a statue of Jesus on the Cross, saying “I thirst”.  While our patient attempted to quench her despair by kerosene, we all thirst for some small measure of peace, and by giving unto others, may hope to achieve it.  It is my genuine and deep hope that readers can help contribute by volunteering time and perhaps organizing some training and support in basic emergency medicine and care, as well as equipment, medicines, and resources for the sisters and staff there, who endow the word missionary with new spirit and old meaning every single day.   The sisters who provides relief to the surrounding society in its darkest hour of need can use all the help they can get.  And for those who have the fortune and privilege to visit and give of themselves, life and its preciousness and the smallness of our daily vicissitudes are all put into clearer perspective. 

Falling into Quicksand

Next week’s vote on Syria is shaping to be a pivotal decision point for Congress, the President, and America.  I applaud President Obama for submitting this action to a Congressional vote.  In the spirit of contributing to the discussion, I would like to lay out my rationale for why I think the Congress should vote no on what is being debated.

This may seem surprising in view of my long-standing position as a liberal hawk and as one who supported the Iraq war.  First off, let us stipulate that Assad is an extremely awful tyrant and that his use of chemical weapons is an affront to humanity. Leaving aside the historical fact that Saddam Hussein was an extremely awful tyrant and that he used chemical weapons in Halabja in 1988,  the real issue at hand is whether the American military response that is on offer will make things better or not?  As far as I can tell, the military action being contemplated does not have a plan for:

•  “the day after and the day after that”
• Removing Assad and installing a decent government
• Securing or destroying chemical weapons in Syria
• Setting up safe, no-fly, no-drive zones for civilians
• Destroying Assad’s air-force, ports, and artillery
• Defanging foreign (al Qaeda, Hezbollah, and Iranian) forces in Syria and supporting the “good guys” (e.g., the Free Syrian Army)

Hence, I must come to the conclusion that what we are planning to lo is little more than narcissistic message-sending about red lines. Not only will this not make things better, it has a very good chance of making things much worse with all the risks noted in the previous post.

I supported the Iraq war, not because of the inaccurate de jure rationale of getting rid of Saddam’s WMDs, but because I thought it would be in America’s strategic interest as well as improve the lot of Iraq’s people.   Reasonable people can disagree on whether the Iraq war served our strategic interest and helped Iraqis in the long run, and even if so, whether it was worth the cost. To digress for a moment, I maintain that the post-war planning for Iraq was handled abysmally and appallingly and that the emphasis on WMDs was disingenuous at best, yet nonetheless America’s strategic interests and Iraqis’ long-term welfare were served to some degree because:

1. For decades after the Cold War, we had 2 major allies in the Persian Gulf, and after 9/11, as it was becoming clear we had to vacate Saudi Arabia, it was a real possibility that we had no allies in the Gulf. The War allowed us to leave Saudi Arabia and still maintain primacy in the Gulf until our North American oil revolution took off
2. Direct consequences of America’s intimidation of others in the Middle East due to the crushing and apprehension of Saddam included the switching of Qaddafi to being cooperative with the West, which led to the roll-up of Pakistan’s A.Q.Khan “Nukes R Us” network, as well as Syria’s withdrawal from Lebanon.
3. Grinding-down of al Qaeda forces which came to Iraq after the war to fight America in a flat desert
4. While tens of thousands of Iraqis died due to American mistakes and incompetence post-war, Saddam was killing similar or greater numbers of Iraqis in his rule, a reign of terror which was ended in favor of a decent chance for Iraqis to make their government worthy to serve its people. Certainly the Kurds and Shiites (who together are a sizable majority of Iraqis) are a lot better off. 

Was all that worth the cost in blood and treasure?  Most Americans would say no, but I would say the answer cannot be known for another decade or two. 

In stark contrast, President Obama’s mooted Syria intervention seems disconnected from improving our strategic position or Syrians’ welfare.  The goal seems to be to punish the use of chemical weapons. But this begs the question, “and then what”?   From the standpoint of an independent observer, we could just as well make an argument for punishing the use of drones or cruise missiles as dishonorable weapons of war that seek to escape risk for oneself.  Secretary Kerry claims he is not asking to take America to war; President Obama claims that he did not set a red line.  They are every bit as disingenuous, if not even more so, than the Bush administration’s pursuit of the Iraq war based on WMDs.  

The Middle East has been a mess for decades, if not centuries. The present conflict in Syria has its roots in the Sykes-Picot agreement after World War 1, where Britain and Syria mindlessly drew lines on a map, and indeed back to the assassination of Muhammad’s grandson in the 7^th century.  If we are to involve ourselves, we should have some idea of what we want an outcome to look like – partition of Syria into smaller ethnic enclaves like what happened in Yugoslavia, occupation by Turkey and allied Arab states, installation of a government that is somewhat decent yet strong enough to manage a transition.  No such objective has been laid out or as far as I can tell even conceived by the administration. This failure of post-intervention planning is even more abysmal than that of the Bush administration’s happy-go-lucky attitude after the Iraq war in 2003.  Our economy and military are in far worse shape than 10 years ago as well.  Let us not step into quicksand for the sake of saving face.