THE FIRST TIME I ever laid eyes on Mortaza was when he was half dead.
He lay sprawled on an untidy hospital bed, breathing rapidly through his lightly pursed lips, struggling, it seemed, to perform an activity you and I take for granted to the point of being unaware of it. His forehead was creased with lines where dried up sweat had left a dark, brackish residue. Elsewhere on his face the same deposits lent the appearance of wrinkles to his otherwise youthful features. His eyes were closed and his lips cracked like parched, lifeless earth. His skin was very dry, crinkling up on itself like a raisin, losing its elasticity with all the water that had drained out of his body. It is called ‘tenting,’ a clinical sign I had learned about when I was a second year medical student—a sign for the severity of dehydration, often suggesting impending circulatory collapse.
My clinical abilities have improved considerably since then. In fact, they have improved so much, that now, as the senior resident doctor in JJ Hospital in Mumbai, I am able to proclaim, as soon as I enter the room, that Mortaza is suffering from Diabetic Keto-acidosis. Had any second year medical student accompanied me that day, they would have gasped in awe that I had made my diagnosis from a distance—spewing off that complicated, mouth-filling verdict before being told about Mortaza’s history, before conducting an examination and even before ordering a single blood test.
Heck, I hadn’t even touched the stethoscope around my neck.
The truth is, it wasn’t my keen perception that aided my diagnosis: it was my olfaction. I could smell the fruity odour of acetone on Mortaza’s breath, the minute I entered the small enclosure in the emergency department that houses the more seriously ill patients, separating them from the drunks, the derelicts and the drama queens who fill up government hospital emergency rooms every evening.
There is a thrill in making a complicated diagnosis so readily. The eyes begin to search for what the mind knows, and, like the pieces of a complicated jigsaw puzzle, events begin to fall into place, explaining stories, signs and symptoms so perfectly that the brain begins to masturbate. The rapid shallow breaths from the deadly increase in the body’s acid content. The sunken eyes—loss of body water and interstitial fluid. The rapid, obligatory flow of urine—the osmotic diuresis of excess glucose dragging water through the kidneys. The rarity of an event like this where symptoms add up with mathematical meticulousness in a physiologically complex and inherently unpredictable biologic system like the human body is what makes this exercise so intellectually erotic.
Perhaps because he provides me with such a stimulating experience, I feel especially kindly towards him. He is what we call in the medical fraternity a ‘good case’ as if to say that the mundane ‘headaches’ and common ‘cough and colds’ are, well, for the sake of propriety, simply ‘cases.’ Besides, Mortaza, just like me, is only twenty-five years old, and this adds its own accent to the valour of rescuing him from near-death.
I turn to the gentleman standing next to Mortaza, watching him helplessly. He keeps folding and unfolding his arms as though searching for something meaningful to do. Amongst others, concern is the predominant sentiment written all over his agonized face. His charcoal-black eyes, moist and red from tears, fidget nervously in their sockets, looking at me and then looking away. His features are gaunt, like those of someone for whom hard labour is a way of life. A thin salt and pepper beard connects his sideburns, framing the lower edge of his face like a tight, angular necklace. His short, wiry frame is clothed in a plain white kurta and a checkered blue lungi. His hair is white and partly balding, and his scalp peeks though the gaps on the knitted prayer cap on his head.
‘He is very sick,’ I say, ensuring that my voice carries the gravitas of such prognostication. ‘His sugar is very high and there is too much acid in his blood. Besides, he has lost so much water that his kidneys might get damaged.’
His hands fold up immediately and he bows his head as if praying to me. ‘Ji, Ji. Allah ka morji, doctor babu,’ he says in accented Hindi.
The seven words he utters tell me instantly that he is from Bangladesh. Although less dramatic, this diagnosis of mine is as infallible as the previous one because my grandmother was from Bangladesh and spoke to us in the same dialect that we called ‘Bangal’ as opposed to the ‘Bangla’ we speak at home.
A gush of nostalgia floods me. I am suddenly reminded of Didu, my grandma, who raised me as a child, caring for me after my mother had passed away when I was only six years old. I have more memories of her than I have of my friends or anyone else in my family. I can still feel the touch of her callused hands that somehow felt rough and smooth at the same time. Her skin was thin like gossamer and sifted to touch as though it had lost its tether underneath. Her hair smelled of hibiscus oil and her lullabies had comforted my sisters and me to sleep on many a warm summer night.
‘Is he your son?’ I ask the man.
He nods.
I let out a small sigh and say, ‘His condition is so bad that he might not survive. He might die as early as tonight.’
The man’s eye well up with tears. He wipes them quickly, raises his hand as though invoking the divine and says ‘Allah’r morji’. He lowers his head and steps out of the room.
I turn to the task at hand. I place a central line in Mortaza’s jugular vein, noting how the blood looks thick and viscous upon aspiration. I use that to send off some laboratory tests and begin an infusion of insulin. The other port hooks up to large bags of saline. I catheterize his bladder and instruct the nurse to quantitate his urine production on an hourly basis. I leave detailed notes on when to start potassium supplementation and how to change his fluids over time.
There is magic in the way insulin works. Magic is the only explanation for the way it hones in on a small docket of protein on the cell’s surface—its receptor—somehow finding its own needle amongst the haystack of a million other such receptors dotting the cell’s exterior. Magic is how this molecular kiss suddenly revives the cell, unlocking its life saving potential as it carries a new message to the cell’s internal machinery. The organelles inside that have thus far been churning out harmful keto-acids under the mistaken belief that the body is starving, immediately realize their folly and shut off this process. Then, in a complete volte-face, the same cells begin hunting and trapping glucose from blood, stacking them like bricks, block upon block, building an enormous trellis of sugar in the liver called glycogen. As if in penance for their erstwhile transgressions, the cells now start changing the remaining keto-acids into bicarbonate, a buffer for all the acid they have produced, neutralizing the deadly hydrogen atoms before they can do any more damage.
If this isn’t magic, what is?
After five or six hours I go outside to look for Mortaza’s father. I find him sitting on a bench next to the registration window, staring blankly at the notice board next to it. I walk up to him to update him on his son’s progress and inform him that his son—although a little better—isn’t completely out of danger. He receives the news with such dispassion that I’m worried that he hasn’t understood me. I repeat the message and ask him, ‘did you understand what I said?’
He nods but doesn’t say anything. His eyes are shifty and seem desperate to avoid drawing the attention of the two policemen standing next to the entrance.
I ignore his skittishness and ask, ‘Would you like to see him?’ He nods … this time there is no mistaking his enthusiasm. He bolts from the bench and walks with me, matching my steps and hiding behind my frame till we are out of the policemen’s field of vision. Then he suddenly jumps in front of me and cowers down, begging for my forgiveness, praying that I’ll pardon his impertinence.
I’m confused.
‘Police … doctor babu, they look for Muslims like us from Bangladesh. They want to send us back. I couldn’t speak then because they would have recognized me and taken me away . taken me from Mortaza and locked me on a train to Bangladesh. Forgive me, doctor babu, forgive me!’
I’ve read about it in the newspapers. The right-wing government in power is rounding up Bangladeshis by the truckloads and loading them onto trains headed for the Bangladeshi border. There is little identification these people carry that would differentiate them from Indian citizenry and so something as flimsy as the Bangladeshi accent is often all the police have to go by. They conduct their raids on shantytowns and charitable shelters, recently widening their search to free government hospitals where such homeless, penurious aliens abound. Like me, most people read such news articles with a benign disinterest, finding limited empathy for foreigners when their own lives are so hard and demanding.
I nod to indicate I take no offense. He immediately reaches out and takes my hand in his, holding it against the side of his face as though kissing it with his eyes.
His hands are callused and his skin is thin like gossamer.
I speak to my father about Mortaza that night. I tell him that I’m reminded of Didu every time his father says anything. My dad listens silently for a few minutes and then asks, ‘Are they here illegally?’
‘Maybe … yeah, I think so,’ I reply, somewhat surprised that his interest in the story is political not medical.
‘Well, the sooner they get them out, the better,’ he says.
I’m shocked. ‘Why? What harm have they done, Baba?’
‘They have their own country, don’t they?’ he says. ‘They celebrated when they wanted to break into a Muslim wonderland, didn’t they? So why don’t they stay there?’
‘This boy is sick, Baba!’
I hear him smirk and say, ‘Did they think about that in 1947 when they were killing Hindu men and raping our women? They were burning down village after village, hacking children and babies. They bathed in our blood and now want our help? And I’m supposed to feel bad for them? Did you know Didu’s brother and two uncles were burned alive in their home in Dhaka only because they were Hindus who didn’t want Bengal partitioned? Do you know after Didu’s family managed to escape to India, they had to live on the streets of Kolkata for almost a year because of these beef-eating bastards?’
It’s magic all right, except that we are doctors, not magicians. A magician knows what he is doing, a doctor does not. He can only offer explanations for all what he knows, but knows he knows very little. The magician, on the other hand, knows every nitty-gritty detail of his performance, down to the last millimetre his wand must stretch to ensure that his act is a success. That is a luxury I don’t have. And so after twenty-four hours, when Mortaza isn’t waking up and only responding with grunts when I rub his breastbone, I’m left wondering if the magic is lost.
I track the signs and they tell me a different story. His blood pressure, pulse, respiratory rate and temperature are normal, and because I’ve had little to eat that day, his sugars are probably better than mine. There is no acid in his blood that I can find a trace of and he is urinating like a racehorse.
But, he doesn’t want to wake up.
This is the hardest part about being a doctor. Explaining something to a layman that I don’t understand myself. Besides, I find that my initial enthusiasm has dampened somewhat after my father’s descriptions of all the horrors inflicted on Didu during the devastation of India’s Partition.
I attempt a jumbled-up, long-winded explanation that I hope will be ambiguous enough to convey Mortaza’s mixed clinical condition to his father. It is mostly an attempt to convey what I truly don’t understand without saying that I don’t understand what is wrong. I’m not trying to be disingenuous: even this has a therapeutic angle. I have learned that often things get resolved if we sit on it for a day or two … a therapeutic manoeuver that some authors of medical textbooks have termed, in all seriousness, ‘Masterly Inactivity.’ Besides nothing unnerves a family member more than a doctor admitting he is completely clueless.
Masterly inactivity … after all it is magic, right?
A new day arrives without bringing back Mortaza’s sensorium. Now, I am really worried. I want to get a CT scan to peek into his brain, but his father cannot muster the seven hundred rupees it’ll cost him for the procedure. He tells me he will travel to his friend in a northern suburb to arrange the money. That is a day’s adventure, losing precious time, when I know that time is of the essence. I decide to hasten the process by paying for the CT scan while his father is gone to gather the amount.
Seven hundred rupees is often the price of life. That is it. Seven hundred rupees will decide if a twenty-five year old lives or dies. It is about a fifth of my salary and not exactly chump-change for me either, but my priorities are pretty clear-cut. I arrange for the CT and await its findings.
This is another form of magic. Magic that human beings have created with ingenuity that I cannot even begin to understand. As Mortaza slips into a doughnut shaped chamber, X-rays shoot pictures from around his head, penetrating his skull, zooming through brain tissue, cutting across blood vessels, nerves and bone, and reaching the other side without bending a single hair on his head. Computers measure their characteristics, working through mathematical algorithms, reconstructing the tissues over tiny differences in intensity, spitting out images that look like someone has sliced Mortaza’s head into neat slivers—much like a loaf of bread—and laid it out in front of me to study. And it is in one of these ‘slices’ as they are called that the radiologist notices a thin web like collection at the base of his brain. I exult because I know what it means.
I told you, it is magic.
I perform a lumbar puncture and start treatment for tuberculous meningitis even before his father arrives with the money. Along with anti-tuberculous medicines, I remember to start steroids. Often, under the aegis of such treatment, the body’s immune system wakes up from its slumber and begins healing with such enthusiasm that it does more harm than good. It can mistakenly tie off nerves exiting the brain, leaving such patients unable to gulp food when the exquisitely orchestrated synchronicity of the gullet muscles in the simple act of swallowing is thrown out of gear. I don’t want to see Mortaza with food leaking out of his nose when he gulps, and so I use a good dose of steroids to suppress the body’s immunity from becoming unduly exuberant.
I’m rather thrilled at having made the diagnosis; a thrill that makes me feel charitable enough to lie to Mortaza’a father that the CT scan was a ‘gift’ from the hospital. He is overjoyed, and again goes through the same ritual of kissing my hands with his eyes.
His skin does feel like gossamer.
The next day I walk in to find a couple of policemen asking the nurses about the presence of Bangladeshis in the ward. They claim there is a state directive to arrest such aliens and prepare them for deportation. They brandish a piece of paper from their pockets and wave it in front of the nurse’s nose, drawing their authority from whatever is scribbled on it. Understandably, the nurse is scared and stares beyond them to look at me just as I enter the ward and stop behind the two men.
The policemen turn towards me. By my looks I am junior enough that they don’t think it is necessary to accord me any more respect than just straightening up their plump figures and reiterating their words. This time, instead of brandishing the paper, they hand it over to me when I stretch out my hand.
The writing is in Marathi and I cannot understand what it says. I look at them and say, ‘There are no Bangladeshis here.’
The two of them stiffen.
From my location I can see Mortaza lying on his bed. He looks the same as before and I want to go over and see if his sensorium is any better. His father is not around and I’m thankful for that.
‘But we have heard that a Bangladeshi patient and his father are staying—’
‘Then go and find your Bangladeshi,’ I snap at them. ‘What do you think . I ask my patients if they are Bangladeshi or Indian or Pakistani before I treat them? Will I treat a Bangladeshi different from an Indian? If they come with a headache will I give him an aspirin and give you an enema?’
The nurse stifles a laugh and the policemen look uncertain. They look at each other and then gaze inside, their eyes resting on Mortaza. I realize that they have come here well informed.
‘What about him,’ they ask me.
I’m not about to give up on my prized patient. I’m not about to give up on my battle with tuberculous meningitis.
‘Take him!’ I say. ‘Arrest him in this condition and see if you can keep him alive from here to the hospital gate. Then, when he dies, I’ll lodge a case of murder against you two. Because that is what this is, murder, if you take such a sick patient out of a hospital.’
The two policemen fall silent, unsure about going ahead with their plans and unsure about letting go of their quarry.
‘Do you have a heart … or has it turned to stone?’ I ask angrily. ‘You are sitting here debating when that boy is dying! I mean, have some feeling, some emotions in your heart. People don’t kick a dying dog … this is a twenty-five year old boy!’
They look around uncertainly. I can see the shame in their eyes that they are unwilling to admit. Then, with the sheets of paper folded and tucked into their pant pocket, they begin to walk out of the wards, slowly, deliberately, as though such meandering canter was always their plan.
I am relieved they haven’t called my bluff. I walk towards Mortaza to see that he is in the same state, neither better nor worse clinically. His father materializes after ensuring that the two policemen are out of sight. He stands behind me, his hands folded, his perennially moist eyes staring at the floor.
It is another one of those situations where things don’t add up. Why isn’t he waking up? Is it too early to expect a clinical response? Should I repeat the CT scan? How will his father pay for it this time?
I’m tempted to prescribe ‘masterly inactivity’ again and sit tight for a day, hoping that situation will present an automatic answer with such benign indifference. I don’t have any bright new ideas to explain Mortaza’s refusal to awaken and again have to rely on my powers of discombobulating speech to inform his father of my thoughts on the matter. His father nods and thanks me.
I desperately search for some magic.
By the time the fifth day rolls around, Mortaza is much worse, threatening to return to the condition he arrived in. His breathing is laboured and he grunts and gasps frequently, occasionally coming within minutes of stopping all activity.
I am aghast. I am at a loss. I am angry.
Most people with tuberculous meningitis recover. Most wake up within two or three days of getting the necessary medications. Most walk out of the hospital with a bunch of medicines in their hand and a vow on their lips that they will take those medicines religiously for the next nine months.
So why won’t my patient … why won’t Mortaza?
The nurse calls me to draw my attention to Mortaza’s nose hair. There is something strange about them, she claims.
Nose hair? Since when did we start worrying about a patient’s nose hair? I am inclined to dismiss her frivolous concerns but decide to look for lack of a better thing to do.
Strange? Strange indeed. For I’ve never seen nose hair like that, peeking out of just one nostril like a bunch of flowers, grayish, dull, and almost blocking the entire orifice. The nurse is more adventurous than I am and ventures to touch it with a ruler. To our surprise, the ends break up and fall off like ash from burnt wood.
That is when it strikes me . mucor! The mold that grows on stale bread has now found a human host. Mucormycosis, the rarest and the deadliest complication of diabetic ketoacidosis.
This time I feel no happiness in making this lightning-fast diagnosis of a fungus eating up the inside of Mortaza’s nose, and now, surely his brain. I no longer see the beauty of giving Mortaza steroids to protect his nerves because it only reminds me of how I’ve paralyzed his immune system and, with it, any chance he had of fighting back the fungus. And although I can explain Mortaza’s continued deterioration to this minute like a captain’s logbook, such mathematical meticulousness in the way the story adds up only leaves me heartbroken.
There is a lump in my throat that hurts so much that I dare not swallow. My heart thuds like it wants to break out of my chest. I can feel my eyes film up and turn foggy.
I turn to his father and reach for his hands. This time, I cannot twist my words when I tell him that I’ve missed the diagnosis and that one of the medicines I had prescribed to try and help him, has only made it worse. I find my powers of saying little when talking a lot have deserted me as I hold those callused hands with the light wrinkly skin and tell him that Mortaza, his son, is going to die.
He kisses my hands with his eyes and thanks me profusely. I’m not sure for what. He is crying and I’m desperately trying to hold back my tears. I choke on the words that leave my throat, and now I’m not even sure of what I’m trying to say. He won’t take his face from my hands and keeps kissing them intermittently and telling me that he hasn’t seen a better doctor in the world.
And that is the magic of medicine.