The Girl

I have been a practicing surgeon for about 15 years now, long enough to realize that
while there will be many who will escape death by our hands, some will slip through the
fingers and a few will touch our lives in their death, if we allow them to. Doctors like to
think we are trained to be stoic, to be strong, to be impersonal. We like to think we move
on better, cope better, a show of external strength. But in my case, as in perhaps all our
cases, you move on to the next patient. We live our lives in between deaths. We write
death forms, we take pride in breaking bad news well but we don't often stop to ponder
death itself-that commonality of life that unites us and the dead patient lying in front,
lifeless while we move on.

I am 40 now, not old, but closer to the end than I have ever been. Over the course of my
life, a few people especially close to me have passed on. My grandfathers passed on
within months of each other-one of cancer, one of a stroke. My paternal grandmother
died a few years later. There was the normal grief that accompanies such events but it
was not a shock.
In college, my best friend and mentor lost his life in a road accident. He was 25.

While I was a student, I saw 3 fellow students take their own lives and heard of some
more. I did not know them so it was an impersonal reaction, perhaps more an
exploration of motive than an expression of grief.

The first time it became personal was more than a decade ago and the memory will
always be with me.

It was probably 2001, or was it 2002-it hard to remember now. A decade later, a decade
of frantic OPD's, a decade of operating on noses, ears and throats, a decade of on call
nightmares and post call joys. And of course-a decade of the odd death.
A decade later, I can't even recall if it Summer or Winter? And in the tropical climate of
Pondicherry, devoid of any real seasons, I wonder if that is even a valid question? I like
seasons-they divide time, divide a year, provide a temporal context to memories, but
when all seasons are practically the same, how is one expected
to differentiate experiences, to convey a sense of the passage of time? In the absence of
seasons, does not one day blend into another, a year into another, eventually life into
death, surely, anonymously?

I don't remember her name and her face is now part of an amorphous mass of patients
and faces over the years, a face whose features I will never be able to extract and give
shape to. She-what name should I give her, she, whom I will never be able to completely

forget. And that's where I feel most helpless. I remember what happened to her but I can
hardly remember her at all. She, like so many of my patients, has become an event now.

She was 19, I do recall that, and she came walking in to the OPD, beads of sweat forming
on her forehead and a red "bindi" standing out in contrast to her notably pale skin. She
was in stridor and I could hear it from a few feet away as she stood by the door. Stridorthat harbinger of death, that marker of an airway crying out for help. I called out her
name in a growing panic and asked her to come to the chair where I sat, my pulse rising
with a sense of urgency an obstructed upper airway brings and that few things can
match. She walked over to me slowly with the gait of someone in obvious distress, her
eyes shining bright and hopeful and as she found her way to my seat, her body collapsed
on the patients chair with a loud sigh, as if the seeker had found her messiah.

Me.

I was a second year resident in ENT, in the middle of a very busy day, on call and thus
primarily responsible for all emergencies that day. She was most definitely one such
emergency. She had had some kind of infection for which she had been intubated a
while ago but of course I can't recall for what exactly. It doesnt matter anymore.

Under the glare of the 100W light of my Bull's lamp and under a ceiling fan rotating with

a reluctance that had never been fully addressed, I proceeded to check her case notes, do
a quick check of her larynx and then rush her to the Ward to wait for a tracheostomy-the
only procedure that would save her life and something I was well-versed in, by now a 12
month veteran of the ENT Department. A wheelchair was arranged, for any more
needless physical exertion could worsen her condition at any time, and I initiated the
Surgical Protocol-start Intravenous Access, get an urgent X-Ray of the Neck, inform the
OT that an emergency was on the way. Standard procedure, done on automatic, done
many times before. Throughout this whole scene, enacted with a degree of control borne
of experience, she was composed and calm and obeyed all that I was telling her to do, in
my rapid English that was being translated to Tamil by the posse of nurses who now
surrounded her, changing her clothes to the bland whites of the patient bound for
surgery- an orchestra of activity, synchronized to precision.

I was not alone, of course. There were two of us that day, two young surgeons with
enough tracheotomies under our collective belts, enough confidence to know we should
be OK, enough experience to know things can turn sour quite fast. She had a stenosis-a
narrowing-of the airway. The X-Ray showed that quite clearly it seemed at the time. The
plan was to expose the trachea and insert a tube through which she would breathe, the
tube being inserted just below where the narrowing ended, the standard plan for such
cases.

She was wheeled in with her aged father looking on, his face receding into the distance
as the trolley disappeared into the sterile OT complex. I never looked back at him as he

must have watched his daughter surrender her fate to two doctors entrusted with saving
lives, with returning his daughter back to him. I never looked back, but I'm looking back
now, scanning my memories to see if I can see his creased, worried face but I see
nothing.

Inside the OT, things went like clockwork. The incision was made within seconds and we
proceeded to dissect the tissues over the trachea in quick time, a scalpel in one hand, a
retractor in another, a nurse daubing the small amounts of blood with a sterile gauze
and the Oxymeter showing an Oxygen saturation in the 90's. All clockwork, all routine
till we exposed the trachea.

But there was no trachea, none that would take a tube, of any size, even an infant
feeding tube. Her stenosis was far worse than the X-Ray showed. She was breathing
through a tiny hole just above where the trachea starts. The usual OT table talk changed
to rushed, hushed, urgent whispers as we rapidly cut further down, almost till where the
neck meets the chest, oblivious of the increasing bleeding, desperately trying to get hold
of an opening, anything that would relieve the stridor, which, by now, was audible even
outside the OT doors. She was dying and we knew it. But we were doctors and saving
lives was our job. We had been there before but the endings had been happy.

We cut the trachea again further down. No lumen. We cut again, further down. No
lumen. The saturation started dropping and the oxymeter sounds started slowing. In the

end, we never managed to make an opening into a lumen. Nothing would go through the
tiny hole we spotted. In front of us she slipped into silence, that sudden absence of
breathing that every airway surgeon dreads. The sounds became fainter, the saturation
continued to drop and we could no nothing. The team of anaesthetists surrounding us
tried all they could, but she let go, her tired, oxygen starved body gave up. In front of
me, she became my first death in which I had been a participant.

I wish I could recall how I faced her father standing outside, with a hope on his face it
was our responsibility to realize, and now, our duty to erase. I wish I could recall what I
said, if anything at all.

As the years wind down, I suppose one should be grateful for what one still has, the
memories time has been kind enough to allow us to still cherish. But I cannot help
rewinding the store of my memories to that day in Summer, (or was it Winter) when I
lost my first patient.
And I think of what she would have felt in her dying moments. What would she have
wished for? To see her father again, standing barely 10 feet from her unaware he would
never see her smile, laugh, cry, and breathe again? Did her life flash before her eyes and
in that flash did she see me hunched over her neck, scalpel in hand, trying desperately to
keep those memories still alive? Did she have any regrets? Did she have time for such
thoughts?

I think about my own death at times. If I am fortunate enough to be given notice, what
kind of life will flash before my own eyes? What regrets will I carry? Is it possible to die
happy without a life lived as one's own?

I can do nothing except move on, learn to be more human and accept that death is my
fate too.
But what of her? She will just be she, the girl who died in front of my eyes, leaving me
with a faint, residual perhaps irrational guilt I may never assuage.
I am now 39. But she was just nineteen. And she will always be.

Dr Nishikanta Verma