Saturday, April 16, 2016

Holding on vs releasing

There are a few very sick patients in ICU as of now.

One man, in his 50’s who came into causality and arrested there, possibly due to intra-cerebral bleed. The admitting doctor did an excellent job in resuscitating and putting him on the ventilator. But the patient due to the underlying disease situation, was already brain dead. He is now on ventilator for the past 4 days. The family wants him kept alive, because the daughter’s marriage is coming up in the next few days. If the father dies or any death happens in the family, no marriage can take place for more than one year. And the extended family wants to avoid this complexity. And we have been requested to make it sure that he remains “alive” till the marriage is over.

There is another man, in his 40’s who is in and out of supportive ventilation after a pesticide ingestion. Though he wanted to take his life, today he wants to get out of ventilator soon. But as and when his wife comes in, his attitude changes – he gets angry. This is the same person about whom I wrote earlier in the blog on suicides. It does appear that there is something going on between the husband and the wife and he is not too keen to see her. But the desire to live is there. She also wants him back, because she says – I have 2 children, and no family support. She cannot live as a widow. (though there seems to be someone else in her life). Widowhood in this part of the country is challenging, both for her and her family’s survival and status. So the husband has to be kept alive somehow!

There is another lady in her late 70s who came with Septicaemia. She was on a visit to her family from Mumbai and fell sick and was brought in yesterday. Now she is on ventilator and being supported by various treatment modalities. Her son is quite keen that nothing happens to her. He told me, she has been quite non communicative and silent for the last one year (? Depressed) but otherwise has been well. Her presence in their lives itself was enough. One could see the love of the son, in his eyes when he asked us, will she get well. A desire to see his mother alive and well.

And there is this 13-year-old who has been with us for more than a month now, in and out of ventilation after a pesticide ingestion and multiple complications of the same. His father constantly keeps talking to us. He wants him alive somehow. The reason – he has three girls and only one son. So the son has to be kept alive. Like without a male child, is not thinkable for a family who has many compulsions due to the cultural expectations. He is willing to sell the little land and house he has for the sake of the son.  I was not sure, if this was one of his daughters’, the attitude would have been the same? (maybe I am seeing beyond what I should see). But whatever it is, the love in his eyes for his son, one could see and experience when we talk to him.

In each of these families, you see the love and desire to hold on to the life of their loved one – just because they love them. And they are willing to do anything possible for that. But in some of these situations, the holding on to life is also made complex by other cultural issues. Loving is about holding on to those whom you love. Loving is about releasing when time comes to release. Health care practioners get caught between the dilemma of helping families to hold on versus releasing when it is time to release. But to understand and make others understand that releasing also is loving, giving up is part of loving, is not an easy task. And to understand the socio-cultural back grounds of the people whom we see and interact, as we help them to release – a much more tougher task.

Why wasn't I taught any of these in Medicine?  

Thursday, April 14, 2016

Confused as usual

We see every day on an average, one to two suicide attempts. A few years back what we would have seen was primarily young girls, or recently married girls coming in with suicide attempts. And the issues which they faced had some commonality. Stories of dowry, in laws , and other gender related issues. Today what we see is a totally different profile. Sometime later I will try to share the detailed demographics, but for this ramblings – a broad capturing of some profiles are being used.

We have seen children as young as 8 to 9 years and elderly as old as in the 70s with stories of varied issues which has led them to explore a quick way out of this world. We still see a few women with gender related family issues who come with suicide attempts, but much less than what it was.  

In an era when we are projecting our nation as the next destination for the world, the next economic super power, a world leader for many of the issues which the world faces today, for some of us, who are working in contexts like where we are, these stories are a stark reminder, that we are still far away from being a happy nation, as we promote ourselves to be.

3 stories of patients who are currently with us in the ward.

65-year-old lady, brought to us with Organophosphorus (OP) ingestion, (diagnosed based on the clinical presentation, relatives vehemently refused any over dose of drugs or toxins) in pulmonary fluid over load, and respiratory failure, after coming out of ventilation and supportive management, told us confidentially her story. The daughter in law, made her drink the pesticide, because she wanted the land and property written off in her husband’s name. 

This is not a one off story. With the upwardly mobile lower middle class and empowered sons and daughters in laws, unlike the mother in law syndromes of the past, elderly neglect and abuse is becoming more common. We find elderly coming in to OPD with insomnia, fears, anxiety much more than what we used to see in the past. We have had elderly being admitted with similar suicide attempts because the sons have tried to put pressure on them to write off their property. We have a family – grandparents in their 70s are taking care of their grandchildren from youngest son, because the elder son has kidnapped and possibly killed off the younger one, again for property and assets. Now the parents are living in fear of the elder son.

The upward mobility, the economic change seems to be ushering in an emerging cultural context – neglect and abuse of elderly……and effect is suicide attempts….

Yet another man is now with us, on ventilator, after OP ingestion. Though initially no clear facts were known, over last four days’ stories emerged. His wife was always accompanied by a man (not related to her), and the wife turned around and told us, please save my husband’s life. She also said, husband and this other man is all I have. Lower middle class family, it is unusual in this part of the country to have a non-relative caring for a lady whose husband has tried to commit suicide. We called the man who was accompanying this lady and asked him some pointed questions about the background of this family. He is the owner of the house in which this family is staying. The husband of the lady, has run into about 20 to 25 K debt (took loan from this owner –? money lender) and since they are in trouble, he wants to help him! The husband is an alcoholic and took or (was given) alcohol mixed with drugs a day prior to this. He had shared this when he was brought in. There are things going on, beyond what is told to us. Was it inability to fulfil the desires of the family, the debt cycle they have got into, and the money lender nexus? One will never know the full story. 

There were others too in the past, men who were admitted with us, who tried to take their life because they could not fulfil the economic desires and dreams of their family, and challenges of the debt cycles they have got into….

The context and situation again is where economic pressures of the lower middle class family, in rural India, complicated by alcoholism, debts and money lenders, women being used as pawns in the game of lending and borrowing, pushing young and middle aged men to end their lives….

There is this young boy with us, 13-year-old, who has been with us for more than a month. He was on ventilator and support for three weeks, now slowly trying to be weaned and supported to come out of ICU. No one knows what really happened, but what seemed to be emerging is (or what was told to us) that he by mistake took a bottle of pesticide and drank! This story is something which we hear every other day - by mistake drank pesticide. When one asks, how can pesticide be kept where children have free access, the answer always is, it is kept along with other bottles, and they were looking for water and drank this. We were told by the father that he had seen his father and friends drinking alcohol, and after they left wanted to try the same. Took a bottle and drank, without realizing that it was pesticide he was drinking and not alcohol! But at the same time, mother had a different story to tell, that he fought with her for something and in anger decided to end his life.

There was another boy who was discharged after being with us for more than three weeks. Less than 8 years, brought in with all signs of pesticide ingestion, but no history of the same. Parents refused to have any knowledge of his ingestion and he also went through a series of supportive therapy. The day of discharge, he was screaming out, “me ne jahar pilia tha...” There has been another 8 year old who drank poison because parents did not give mobile phone of his choice. Another boy who failed in exam and tried to end his life, at a young age of nine…. Most of these are not well off people – lower middle class or poor.

Yet another emerging cultural phenomenon – children and young trying to end their life, because their expectations are not fulfilled….or they are not able to fulfil others expectations…

Many such stories we hear each week. All these stories have some common features. 

All of them are about expectations and aspirations that could not be fulfilled. Most of these aspirations are linked to money or aspects of upward mobility.  The precipitating event in some of the situations are insignificant, and this is a sign of much long term and deeper discontentment.  A small event becomes the tipping point. And very few contexts only, we come to know the whole story….

When money and GDP is the focus of a Nation, when visions and aspirations are shared without setting in systems of implementing these visions and ways of reaching these aspirations, when there is much talk and little action…..does one need to expect anything more….?

Godliness with contentment is much gain – but when money becomes God, contentment is replaced by greed. But when money becomes God in the context where basic needs and desires even are not met or fulfilled….what else will people do….? 

Stations on the Road to Freedom

Dietrich Bonhoeffer(1906-1945) Discipline If you set out to seek freedom, then learn above all things to govern your soul and your sense...