Letting Dr Mukti go!!

My mother Dr. Mukti Bhatnagar is a role model for many including me. Without doubt she loved me the most of all her students, friends and relatives. The same was true for me. Although it is obvious for the relationship of any mother and son but ours was slightly more than that, we used to understand each other at a different level, and we used to joke -some of them were only understood by us-, professional discussions and mutual guidance. Discussions and fights on achievement of perfection in various fields including spiritual, horticulture, arts, emotional, medical, administrative, music and the list goes on. It was her habit to be perfect. I could talk to her about anything including the intimacy with my wife, we would make various jokes about that too. She waited for me to return from office and I returned from my office for her rather than anyone else.

During my MBBS she was my teacher in medicine but to all of us she taught how to be a human before being a doctor. How your decisions and actions should include the emotions of the patients and their family. How to be observant beyond what the book and the investigation shows. She did not want me to become a surgeon, I was good in medicine (subject in MBBS) and most other medical subjects but I was always found the theoretical part of surgery (subject in MBBS) boring. It was only about cutting and joining or opening and closing. I talked to her that medicine was always with me and that how being a surgeon I could always do medicine related treatment but not the other way around.

In the last week of April I was being framed by some corrupt government official for a heinous crime as per my values due to some personal benefits that he had been refused. I was on the move. While I was not with her I got the news that she had acquired covid. Just bad timing. I knew that it could be deadly considering her present condition.

She was a fighter. She got breast cancer. Doctors are bad patients and hence it was detected late. After completing the treatment and against the verdict of the standard medical literature she got metastasis after completion of the danger period of spread that is known for the type of cancer she had. It was strange from the medical point of view. She had extensive mets but all were in her bone, nowhere else. She got treatment for the same and once again, against the medical literature available she responded well to it. Around 6 months before she got covid, 1 metastasis was detected in her liver. Both she and I knew what it meant. She discussed it with me and wanted to hear the truth from me. Although she was an authority in almost all the diseases but cancer was my field with more recent updates favoring my knowledge over hers. I used to tell her the limited favorable things that she was supposed to know and hide all the bad things. Then she used to look at me and say “both you and your father think that I am a fool but remember that I still know more than you do” and then while looking at each other we used to smile and laugh. Both of us knew the truth and both of us knew what I was trying to hide, but we could always laugh about it. That was the mental and emotional strength that she and I gave to each other.

Surprisingly with some palliative chemotherapy and non-allopathic treatment we discovered that about 3 months back the liver secondary had magically responded to the treatment. Her diseases had failed medical literature before and possibly it had beaten cancer also

I guided her treatment to the best possible and within 10 days she was negative for covid. Uneventful despite her high viral load. When I returned home I saw my old mother. Back to her normal. Nothing more than minor aches and pains. As vibrant as always. Sad that despite the selfless work that had been done some officials are so corrupt. She guided me. Then once again we laughed that “ab to covid bhi ho gaya”.

Despite her being negative for covid I could see that she was weak. However, She was most distressed that her lines while painting were slightly wiggly (they were actually as perfect as always to me, but she was not happy with the finishes). Her weakness increased, I wanted to give her time but she told me that my expertise of critical care in covid warranted that I should see the covid ICU. Once In ICU I used to lost tract of time. I used to come home late. She was weak but used to manage to come out to sit with me and ask me about my patients. I was noticing how her appetite was reducing. Finally I decided to get her investigated and discovered that the covid inflammation was continuing and the disseminated coagulation was continuing. It had affected her liver also.

Soon father was back and despite all the work that he had he made sure that every single thing that a nurse does was done by him. He said I could not be with her ever. At least during her illness I should be with her. He is also my idol and continues to be so. Despite all the work that he has, he managed to give every single medicine that I had prescribed himself.

The three of us had a discussion and mother was against her getting admitted under me. She said that she knew that I would give her the best possible care and also that she knew that I was better in medicine that a lot of other physicians but she did not want the burden of any unfortunate outcome to be on my head.

On the other hand I knew the seriousness of the illness. I had told father that off all the complications of Covid, DIC (disseminated intravascular coagulation) is possibly the worst and possibly the one that I had always wished that I did not have to treat. DIC is a state where the inflammation in the body leads to clotting of blood inside the body at places where it is not supposed to clot. The clotting uses up the store for blood clotting and makes the person more vulnerable to bleeding from other areas. The treatment is also contradictory. An anticoagulant is given to stop the clotting and coagulation factors given to stop the possible bleeding. I had also seen how senior people could be biased in taking the correct decision when it comes to treating my parents. Treating such senior people of such immense personality and importance and persona is possibly the most difficult aspect. I was however used to it. I am still of the opinion that treating one’s own parents is a very difficult skill and should not be taken by doctors. It needs the highest level of mental and academic composure. I realized that the burden of treating and possibly losing Dr. Mukti was too big for any other consultant. The society and other consultants would have always cursed the treating consultant for negligence and less than perfect treatment. Possibly, I would have found an excuse to curse the treating doctor also.

Assessing everything, I finally admitted her under myself. I took guidance from the best doctors and diagnostics for the treatment. All of us knew the prognosis but neither once did we say it to each other.

During her treatment she was very weak, eating very less, some brief spurts of energy were there when she used to be back to her normal self. With the progress of the disease the duration of her normal self reduced significantly. I could see from her reports how her organ systems were collapsing slowly under the dreaded complication of DIC. During one of her normal periods she asked me softly, not looking at me. “Do you think I will be cured?

”, “O ho, you don’t know what the medical science has come to. With the recent medications you will be up and about in 2 days.” She managed a glimpse at me and said “I still know more medicine that you” and then to my surprise and joy she managed a smile at me like previous times. Both of us knew what she meant. I held her hand and smiled back. I am not sure if she saw that but she knew that I was there.

Slowly her period of normalcy were very less, not more than 2-5 minutes in 6-8 hours. We relished those. Around 4 days prior to her demise she got up from her bed and called all of us. She came outside her room and asked us to sit and close the door. She waited for the commotion of our visible cheerfulness that we had after seeing her like this to settle and then spoke, mainly to me. Parts of it are: “you are my son and you will never stop trying to save me but I don’t want to be remembered as a liability and in this state. I want all of you to remember me as me. Let me go as Dr. Mukti.”
She went back to her room and became the patient.

Slowly her oxygen requirement started increasing and finally she had to be admitted in an isolated ICU. The family members continued caring for her. She became jaundiced because of the DIC taking over the organs including her liver. She used to call out my name consciously or unconsciously and I used to be there.

I could see that ventilating her was an unavoidable eventuality. It was hard asking the sister to arrange the items needed to ventilate, to ensure that all the drugs are there. It seemed I was running out of the memory of the drugs available for this reason. Who will intubate if needed? Whether to intubate or not?
On multiple occasions she had told me that “a time will come when you will need to put me on life support. In that cases I will not consent for being intubated. Let me go peacefully.”
On the night when she was ventilated I just kept on watching her breathing pattern. I kept on saying to myself that if this was any other patient I would have intubated by now but my promise to her was holding me back. I took an ABG to get a hold of reality and to support me if I had to take the decision of intubating her.

Soon, it was obvious that she is fighting for her breath and I took the call for intubation. I wanted to call the critical care specialist but I realized that the burden of intubating the great Dr Mukti was too big for anyone else to bear. I asked the staff to give her the highest possible dose of the best painkiller available. The same was given. Although she was already looking sedated and drowsy I asked the staff to give her a good amount of sedative. I waited for the breathing to reduce to put in the laryngoscope. But it did not. At that time the saturation was 75 and falling. A cardiac arrest was something that I was not mentally prepared for. It was either intubation or an arrest.

I put in the laryngoscope. Due to her mouth breathing because of her illness and the deranged coagulation profile the oral cavity and pharynx were very dry and friable. Bleeding anywhere I touched. But alas, as soon as I reached the pharynx she opened her eyes like before and looked at me. Even tried raising her hand. I thought momentarily that intubation could be avoided and looked at the monitor only to see the falling saturation. I asked the staff to give the relaxant. Both the staff and I knew that after the relaxant, intubation was unavoidable.

Just before giving the relaxant the staff asked me “sir, are you sure that I should give”. I looked into her half opened eyes for a moment. Perplexed as to what is to be done. Suddenly my mind cleared. It was as if she was speaking to me. She said do what you think is right. Don’t let my promise trouble you for life that what if I had ventilated her. I said a soft sorry to her and asked the staff to give the relaxant in low dose. In a moment I placed in the tube into her larynx. Her vocal cords reminded me of the beautiful voice she had and her mastery of music. Connected the ventilator. I noticed that my father was sitting close by distressed by what had to be done.

It was an eventless intubation. As usual I had done a skilled job in intubating a patient despite a poor mouth opening, mallampatti 3 grade (difficult) and fragile mucosa and specially because I did not want to use any force considering the deranged coagulation profile.

Setting the ventilator was a routine and I changed to the best possible settings. Within 2-3 minutes her saturation reached to well beyond 95%. What next? I dint know what was the next thing to be done. The treatment was already at its best. There was no way she could be saved. I said to myself that at least it could be a painless death. Once again with suddenness I had clarity in mind. I got the analgesics going in the best possible dose and reviewed the treatment. Dialysis was the only thing that could save her. I arranged everything in the room.

Although it was clear to me that saving her was not possible but to make the matter worse she improved dramatically overnight due to ventilation. In the morning I got the neck line changed to a thicker dialysis line and we got the dialysis going. The procedure was tolerated well and sadly our hopes became high. Maybe I could extubate her in a couple of days and then again fight with her about the rubbish promise that she had made me make.

I managed to sleep for some time after a very competent junior took over. I had plans of micromanaging her so that we could plan for extubating in a few days. Before sleeping I had sent her samples and waited for the reports to show the improvement that was expected because of the dialysis and ventilation.

I got up in 2-3 hours, don’t know? Loosing track of time. I saw the reports to see that the liver had completely shut down and the DIC had become full-fledged. The necessary treatment was added and delivered and again asked my junior to take over. He was remarkable.

In the evening I asked him to go and take rest but he said that will continue. Soon there were alterations in the ECG and we knew that a cardiac arrest was evident. Perhaps it was a heart attack, but the treatment was already in place.

As expected a cardiac arrest happened and he started the CPR. At first, I said to stop but seeing the perfectness with which the same was being done gave me strength to remember my expertise in the field. I took over the CPR and asked him to take over the drugs. I thought to myself that if the ribs crack then the charge should be on me. I continued the CPR knowing fully well that we had lost her. I asked my father to move out along with my younger sister. While doing her CPR I reminded her that today was not the correct day as it was her elder daughter, my elder sister’s birthday. Surprisingly, she came back with a cardiac rhythm. Strange it was. Possibly the love of her children?

I asked my junior to leave and asked him to leave the night to me. I got the night staff changed to one who gets me the best. I kept observing her and her vitals and her ventilation to keep her pain free. Her hands in mine were cold but still gave me the warmth they always did. Father had come back and I asked him to sleep but he couldn’t. Soon it was 12:00 midnight and the next day had started. I told her that it was ok for her to rest now and that it was ok for her to leave from my side.

At around 5:20-5:30 AM she had another arrest. It was my duty to do the CPR but this time she was adamant on leaving. At 5:50 AM I had to declare her death. I did what was needed. Kissed her and hugged her – the liberty of the same was not there for any other family member, apologized for breaking my promise and thanked her for the lovely moments and the life she had given to me.

The staff wanted me to leave the rest to them, but I insisted on removing the tubes all of which that I had put. She wanted to be Dr. Mukti for everyone and it was my duty to ensure it. After informing my father about the event and leaving the heavy task of informing the sisters about her demise to him I went to her and put cold cream on her face, as vibrant as always.

Dr. Krishna
Proud son of Ma