Unhealthy practices

disease

CHAPTER ONE

As Medical Director of Gopalji Damji Hospital,

Dr Jagdish Choksi was the junior most to attend the meeting. Despite his exalted title, he was painfully aware that his job depended entirely on the goodwill of the seven-member board of trustees. So he took care to arrive at the conference room several minutes before 3 pm, and heaved a sigh of relief because none of them had shown up yet.

As he passed through the sprawling lobby on his way to the meeting, he glanced absently at the two admission clerks hunched over their computer keyboards. They were hurrying to complete the medical records of several dozen patients who had entered the hospital during the morning. The workload was always higher on Monday afternoons because many senior surgeons avoided routine surgery during the weekend.

Just beyond the admission counter, the cashiers were busy preparing the bills of three or four patients waiting to leave. One of them was talking animatedly to the stocky gentleman at the head of the queue, possibly trying to convince him that they were not going to take the whole day to finalize his bills.

Soon I will have to take a really close look at the administration department, he told himself, though he knew the crafty administration manager would not let go without fighting every inch of the way.

As he settled into the chair at one end of the conference table, Dr Choksi opened the bulky file in front of him and removed a thin sheaf of printouts that his secretary had prepared for him the previous evening. She had analyzed the records of all patients, which 14 of the hospital’s senior most medical specialists had looked after in the past three years. It also indicated the revenues that each of them had earned for the hospital in that time.

One of the lowest was Dr Rajendra Kapadia, who always had less than five patients in the hospital at any given time, and most of them were in the general wards. These patients had to pay only Rs 50 per day as bed charges, including meals and the barest minimum for the medicines that they might need. The doctor too did not receive any fees from this category.

But a patient admitted in one of the deluxe rooms on the twelfth floor would pay at least Rs 3,000 per day, and the doctor could charge whatever fees he thought fit. Besides, the surgeons who charged astronomical amounts from gullible patients coming from the Middle East were generally favourites of the administration, since the hospital received a 30 per cent share from the doctors’ fees.

Dr Kapadia had been with the hospital for as long as he could remember, and Jagdish had come to regard him as an older brother, and confidante. Hence for several months, he had deflected every move to ease the elderly physician out. But now he knew he would not be able to shield him much longer. Others too would face the axe sooner or later, for the management was quite determined that they should make way for the younger, businesslike set of consultants who had flooded the major hospitals in the city.

Jerking out of his reverie as Mr. Madhavji Shah entered the conference room, Dr Jagdish Choksi stood up to greet the chairman of the board. Dressed as always in spotless white dhoti and kurta, Mr. Shah looked a perfect illustration of the archetypal Gujarati seth. He had made his considerable fortune in agricultural commodities, buying turmeric, ginger, garlic and dhania directly at low prices from farmers all over Maharashtra and Gujarat, and selling them through thousands of tiny retail provision stores in Mumbai, Delhi and Calcutta. In the past few years, as a receding hairline kept reminding him of his age, Madhavji had taken to wearing a dark gray topi, which he removed and placed on the table. These days he maintained an office on the ground floor itself, just three doors away from Choksi’s own.

Shantibhai Mehta, widely known as the cement king, arrived a few minutes later, followed by Rasikbhai, the founder of Thakkar Developers and then Prashant Kadakia, who at 38 was really the baby of the team. All had identical folders before them containing the analysis of revenues brought in by the different doctors.

As mentioned in the documents provided to you, 14 honorary doctors have generated less than Rs 50,000 annually in the past three years, the medical director began. While he read out the names and the amounts mentioned against them, none of the trustees said a single word. They were all preparing themselves for the vicious wrangling that was about to begin.

It was barely 7 am, but the dining room on the sixth floor of Gopalji Damji Hospital was already buzzing with activity. The stainless steel trays were stacked high, one upon each other, ready for the young men and women in white coats, who would barge in for a hurried breakfast and rush out to begin their ward rounds. This was Wednesday, the day of idli-sambar for the veggies and egg bhurji for the carnivores.

Being a junior resident, Vineeta Mahajan was in a constant tizzy, particularly if Dr Sanjeev Saxena, the chief resident with whom she had been assigned, came in for breakfast ahead of her. This happened not less than twice a week, but that day she was in luck – Dr Sanjeev was nowhere to be seen. As she heaped the idlis on her plate, Vineeta prayed that her superior had not finished his breakfast and left.

As she sank her teeth into her second idli, she felt a hand on her shoulder, and turned around. It was Dr Anil Motwani from General Surgery.

Has Dr Parikh seen that old lady in 904? Can we schedule her for tomorrow? he asked her.

No he hasn’t. But we’ll try to see her today itself, Vineeta said, struggling to speak with her mouth full.

Fishing out a tiny index card from his apron pocket, Anil made a note to check if he had entered the reference in the case paper. Sometimes he thought the hospital insisted on too much paper work, and not enough time was spent with the patients themselves. But with the Consumer Protection Act hanging over their heads, most doctors had no choice but to document every tiny detail in the medical records. In a close call, it could be their only defense.

No OR today? Vineeta asked as the two hurried towards the lift to begin their rounds.

There is a hernia repair in the afternoon, but nothing in the morning, he replied.

The next day, however, there would be a full list starting from 8 am and Anil was going to spend most of Wednesday preparing the cases, making sure that their x-rays and blood tests were done; the reports ready for the pre-operative reviews (by the anesthesiologist) later that night. With any luck, he might be able to return to the quarters in time for the 9 pm television news on Star Plus.

Vineeta’s first patient was on the 13th floor and Anil waved to her as she got out of the lift, but the door of the elevator closed before she could wave back.

There is a referral to Dr Parikh, the dusky staff nurse told her as she entered the ward. She glanced at her watch and decided there was time to see the new case as well. It would save her the trouble of rushing back here before the honoraries began trooping in.

The new patient’s room was just two doors away from her own, and with a gentle knock, she stepped inside. Good morning, I’m Dr Mahajan, Dr Dilip Parikh’s assistant, she said cheerfully, as she looked at the case sheet in her hand. Mr. Veljibhai Narayandas had had a slight temperature for the previous few days and the urine report suggested a mild infection.

Do you come to Bombay quite often? she asked him in a casual tone.

Oh yes. Earlier I used to come at least once a month, the crusty old man replied, my textile business is now managed by my son, ever since I began to have those fainting episodes a few months ago. And his visits to the metropolis had become less frequent.

His blood pressure was 180/110, Vineeta noted, but said nothing. It would have to be brought down before the stone in his right kidney could be removed. Using a standard pro-forma that she practically knew by heart, she questioned him in rapid-fire fashion for any other symptoms, like an unnoticed headache or hallucination that might point at something serious.

Next, she removed an ophthalmoscope from her apron pocket, and examined the eyes, where telltale signs of high blood pressure were often concealed. She found nothing that would worry the anesthesiologist too much when the old man was operated upon the following week.

They all wore the same worried expression, sitting or standing in small groups just outside the entrance of the Intensive Care Unit on the 19th floor. To Yogesh Tripathi, it seemed rather appropriate that the ICU was on the top floor, as though the patients on each of its eight beds had already made their reservations for the journey beyond.

The tightly controlled format of news writing, which had been his profession for the past five years, allowed no scope for such fanciful impressions; but he stored them for some future time when he might be liberated from the tyranny of the inverted pyramid.

Yogesh’s own father had been inside for five days, hanging on to life by a mere thread, as his liver and kidneys were quickly failing beyond repair. He wondered what had brought some of the others here, though he could gauge almost nothing from their faces. Only the balding gentleman standing quietly at the window across the corridor, had told Yogesh he prayed each morning to every deity that he could think of, so that his teenage son would recover.

The young chap had been in a terrible accident on New Year’s Eve four months before, and was quite unable to breathe without the help of a machine. His old man however was unwilling to surrender, and turned up on the 19th floor every single day. Even if the boy did come out of the ICU alive, he would never be able to recognize anyone, much less speak or eat or stand up on his feet. Was such a life worth it? If that wasn’t a suitable case for euthanasia, what was?

Dr Vineeta Mahajan walked briskly along the corridor, pushed the door of the ICU open and just before she disappeared inside, she saw Mr. Tripathi’s son standing near the entrance.

I want to talk with you when I’m through with the ICU, she told him, without breaking her stride.

Yogesh nodded, but she hurried inside before he could reply. He decided to put off his lunch by a half hour, lest he should miss the opportunity again. But when there was no sign of Dr Vineeta after a full hour, Yogesh debated with himself about whether to make a dash to the PCO on the ground floor and telephone his office or wait a little longer.

It was nearly six o’clock when Yogesh reached the Morning Post building, which had become his second home ever since he joined the newspaper five years before. At his level of seniority, there was no need for him to do the graveyard shift; he could concentrate on special stories instead. But that fortnight it suited him because the whole day was free. More importantly, he would be able to hang around the office – ready to rush to the hospital at a moment’s notice in case there was some really bad news.

The Press Trust of India ticker tape, which came directly on the reporters’ computer screens, put out the usual stuff – an accident in Solapur which claimed four lives, a walkout in Parliament over alleged corruption by some minister, a rasta roko somewhere in Orissa. Then his eyes caught something about the Customs department having seized a huge amount of smuggled gold from Sahar airport. Snatching up the bunch of press releases on his desk, Yogesh scanned through them rapidly until he found the one from the Air Intelligence Unit. Then he returned to the video display terminal to prepare the news item worth a maximum of four paragraphs on an inside page.

The canteen boy brought the first round of coffee a little later and Yogesh decided to take a stroll along the corridor to the copy desk, where the next morning’s newspaper would already have started taking shape. It would go through many changes during the evening, but like most days, the important news stories to merit the front page had already arrived on the chief subeditor’s desk.

What’s happening in the city? asked Mr. P K Murthy, the chief subeditor on duty, as he saw the night reporter amble along towards the desk.

Nothing. It’s absolutely quiet on the western front, Yogesh said.

And the city page is empty, piped up one of the junior subeditors.

You can put my photograph, Yogesh suggested.

But that’s only if you retire or die. Company policy, you know.

If it is the latter, our deadline is 11.30 pm. So be quick, Mr. Murthy said, and they all laughed.

Yogesh, there is a call for you, one of the subeditors said, handing him the telephone. It was Pravin Sharma from the Times of India, checking if any accident, murder or robbery had taken place since the afternoon. This was the night circuit, an informal arrangement of reporters sharing information about routine events with their fiercest rivals in the marketplace.

Every chief reporter worth his cabin knew this informal system, for they had all used it in their time. But they always looked the other way, pretending it didn’t exist. Because no reporter could expect to cover the entire city night after night, without missing anything and it evened out at the end of the season.

The phone rang once again, as soon as Yogesh got back to his seat, and Yogesh cursed under his breath before picking up the receiver.

Have you got any details of the derailment near Matunga? asked Subramanium from the Free Press Journal.

No. What happened?

Two air-conditioned coaches of some express train got off the rails between Dadar and Matunga. Five people have been seriously injured. Are you going to the spot? Subramanium asked. Yogesh said he probably wouldn’t, since no one had died and it was already past 8 pm. But he had spoken too soon. Within ten minutes, his chief reporter, Dinesh Khare, called up and instructed Yogesh to leave for Matunga immediately.

I think we should consider the names one by one, said the chairman of the board, as Dr Choksi put the hit list in his outstretched hand. No one answered. Only after a full minute of dead silence did Madhavji realize that the others were waiting for him to begin.

Alright gentlemen, what should we do about Dr Naresh Dayal? With less than Rs 40,000 per year, he is near the top of our list.

He is one of our most senior doctors. It may not be fair to throw him out so late in life, said Rasikbhai Thakkar.

Yes, but he has a lot of property and investments. So he has no need to work, Dr Choksi said.

In any case, he was not earning much himself. So he won’t lose very much by not coming here, said Shantibhai. The cement king had once approached Dr Dayal several years ago for a donation of Rs 50,000 for an orphanage in which Shantibhai had been chief trustee. Dr Dayal had politely declined, and as a result, Shantibhai had found himself in a tight corner. Now was the time to pay the tightfisted character back in his own coin, Mr. Mehta thought to himself.

Dr Rajendra Kapadia was next, and then Dr Narendra Vohra. One by one eight names were scratched off the list; eight people, who would receive polite letters from the Medical Director during the next few weeks, inviting them to discuss their positions as honoraries with the hospital. At the meeting they would be quietly informed that their admission privileges were being withdrawn. The timing, too, was perfect, because honorary doctors held one-year contracts from April to March, which were automatically renewed in the past. But the hospital had given no legal commitment to do so.

By the time the committee reached the ninth on the list, it was 5 pm. The heat of the April afternoon and the intense discussion had sapped their energy despite cups of tea and coffee that came in at regular intervals.

We might have a problem with Dr Gajendra Mody, because his billings were above Rs 2 lakh this year, Dr Choksi said. They had been much lower in the previous two years, almost as if the aging orthopedic surgeon had got wind of the management’s plans before they had even been worked out. Also, the employees’ unions loved him, and both the director and the chairman were aware of this.

But if he is going to stay with us, it might be rather difficult to remove Dr Ramesh Panchal, said Prashant Kadakia, who had kept his mouth his shut till now. Just last month, Dr Panchal had examined Mr. Kadakia’s six-year old son, Anand, who had fallen off his bicycle and broken his left arm. The little chap’s arm was still in a plaster cast, which would only be removed after another fortnight.

You cannot compare the two, just on the billings of one year, Prashant continued, since Dr Panchal had a better record for the year before last. Besides, Dr Mody’s performance might be a fluke.

But Prashantbhai, we have to consider the overall record for three years, Dr Choksi said, wondering if they would be compelled to retain both of them. In that case, young Dr Ashish, who had just returned after completing his training in spinal surgery in Houston, USA, would have wait for a while. Dr Ashish Sheth was also related to Jagdish by marriage, and that had complicated matters quite a bit. Unwilling to give up, Prashant pointed out that the hospital needed senior surgeons who had already made a name, to hold the fort until the younger batch gained the patients’ confidence.

So we have Dr Mody. Besides, Dr Mody is a better surgeon than Panchal, said Madhavji in a tone that said, that’s enough, young man. The youngest member of the team caught the look in the chairman’s eyes and decided to shut up for the time being. But I shall make them pay for this when the right opportunity comes, he promised himself.

Ratna Devi began searching for familiar faces, as soon as she stepped out of the lift on the 19th floor. In the fading sunset that April evening, she wondered how many more she would have to endure. Her son had already left for work; the poor boy was doing the night shift so that he could take care of his father during the day. And he must be getting quite exhausted.

She often breathed a silent prayer that he too would not get into some sort of trouble; she had heard too many stories about press reporters being killed or beaten up, to feel totally safe ever again. But Yogesh had insisted that he wanted to work at nothing else and his doting father had allowed him to go his way in life.

The high society butterfly, whose husband had undergone an operation, was not to be seen. Neither was the old man whose son had met with an accident. Perhaps they were here during the day, and had gone home to rest, she thought, as she moved towards the wooden bench. Two middle-aged men were already sitting, ready to nod off to sleep at any moment. Both men shifted slightly and Ratna Devi squeezed into the little empty space near the end of the bench. Neither of them gave up even a tiny bit of room, but she was in no mood to pick a quarrel just then. There would be enough time for that later in the night.

Through the heavy mist, she vaguely heard her name being called. At first it sounded like Yogesh, but that was not possible because he would have reached at home by then. She rubbed her sleepy eyes, and saw the young man in a white coat standing in front of her. Was he a doctor? What was he trying to tell her? Was her husband dead?

He is completely out of danger, said the deep voice coming out of the ether, so we are shifting him to a regular ward immediately. A hundred alarm bells rang in Ratna Devi’s head as she stared blankly at the young doctor, barely managing to read the name-plate.

But can’t you shift him tomorrow? It is two o’clock in the morning and my son is not here, Ratna Devi said, her mind racing to throw up some pretext, however flimsy, to stall the young doctor.

We could have waited till the morning, but we need the bed very urgently. I have already spoken to Dr Parikh and he has told me that the patient can be shifted out without any problems, said Dr Nilesh Prasad. He handed her a piece of paper with Dr Parikh’s home phone number, saying you can also contact him if you wish.

Better try and find Dr Parikh’s assistants in the hospital itself, suggested someone, as soon as Dr Prasad had disappeared into the ICU. Ratna Devi turned around to see the middle aged man who was sitting next to her for the past couple of hours. But before she could even respond, the ICU door burst open and a stretcher trolley appeared, with Mr. Tripathi barely conscious enough to recognize her.

Two night nurses carrying plastic packets of intravenous saline, practically ran alongside, trying to keep in position so that the plastic tubing and the needles in the patient’s vein would not be displaced. They escorted him to the room no 1017, on the tenth floor, and with an efficiency born out of long experience, quickly explained the doctors’ orders to the duty nurses on the tenth floor.

Mrs. Tripathi raced down the stairs to the pay phone in the lobby, and furiously dialed the number on the chit given to her some time ago. After nearly a dozen rings, she heard a mechanical voice say the mobile number you have dialed has been switched off or is not reachable at the moment. The only other choice was to find the assistants; her adviser upstairs had apparently known that this might