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Into India

Gloom settled palpably about the place. We made rounds perfunctorily, in a dream-like state of disbelief. We performed operations that were on the docket, but no new ones were scheduled. The residents prepared to leave.

Then fate struck like a thunderbolt, abruptly and decisively. Manohar charged into my office, announcing the news: "Doctor Saheb, Dr. Paul is dead! He had a heart attack at home and he dropped dead, just like that!"

How could a single event, a subtraction, solve so many problems? It was a tragedy, no doubt about it. Dr. Paul was in the prime of life. His lonely widow became more reclusive than ever (indeed, many months passed before she could be persuaded to vacate the house assigned to the superintendent). Nevertheless, the atmosphere changed abruptly; the sun seemed to shine again. The training program proceeded as before. I was made acting medical superintendent, as well as director of surgery. I knew I'd now be able to serve out my contract.

Less than a month later, it was again Manohar—grave and bustling with importance—who brought me word of another emergency. "A patient from Ichalkaranji is hemorrhaging, Saheb," he said. "It is Shivaji's brother. I think you need to see him. He's in the second men's ward."

As Manohar and I walked the short distance to the ward, my thoughts flashed back to the boy who had swallowed the railroad spike. Shivaji's brother, Dev, was a TB patient at Wanless. At the ward building, Manohar and I donned face masks and Manohar fetched Dev's chest x-rays. We found him hidden by a crowd around his bed—ward boys (male attendants) and curious fellow patients. Dev was lying on his side, coughing into a basin on the floor that was half full of blood.

A nurse, sitting on Dev's bed taking his blood pressure, looked up. "This boy began to cough early this morning, Doctor Saheb, and hasn't been able to stop. We've tried pituitrin injections and ice on his chest. Nothing has helped. He's lost about 500 cc's so far, but his blood pressure is still okay. His pulse rate is fast, but it's not weak."

Dev was about 20 but looked older. His frightened eyes sought out mine. While I stroked his shoulder awkwardly, I held his chest film up to the light of the sky. "Try to stay on this side as much as possible, Dev," I told him. "We're going to have to take out the upper half of your lung, where your cavity is, to stop the bleeding. We'll try to do it this afternoon, as soon as we can get things ready. Where's your father?"

A patient at the Wanless San, showing off the incision from his chest surgery.

Shivaji's brother, Dev, was a TB patient at Wanless. At the ward building, Manohar and I found him hidden by a crowd around his bed—attendants and curious fellow patients. Dev was lying on his side, coughing into a basin on the floor that was half full of blood. His frightened eyes sought out mine.

"They've sent for him, Doctor Saheb. Please help me."

"We'll do the best we can. Don't worry."

Itried not to betray my own anxiety, but things looked grim. To operate in the face of active bleeding was dangerous, because the patient could easily drown in his own blood. But I couldn't just let the boy bleed to death without trying to stop the hemorrhage. To complicate matters, the man who traveled every week to Bombay, 300 miles away, to fetch the bottles of blood that we used for transfusions would not make it back to Wanlesswadi until tomorrow afternoon's train. We would have to try to persuade the patient's relatives and friends to donate blood, since it was unthinkable to begin surgery without at least four pints on hand. In the past, persuading local people to donate blood had been unsuccessful, hence the need to resort to the distant commercial blood bank. I did not think Dev would make it until the next day, at the rate he was hemorrhaging.

I asked Manohar to assemble family and friends from Dev's village.

"Saheb, you know they're not going to give blood," he told me. "They never do. They are always afraid. That is why we are having to send to Bombay."

"I know, but we have to try once more. This is a really serious business."

Within an hour, a motley assemblage of skinny, scruffy, dhoti-clad villagers, including Dev's father in his purple turban, gathered at the office steps. Shivaji was there, too, still looking a bit frail. I exhorted and pleaded for them to donate blood, Manohar translating. The men looked glum and shifted their feet. Only Shivaji offered to donate blood for his brother. He looked so puny himself, I was almost afraid to bleed him at all; at most, he might be able to safely give half a pint. But that was a ridiculously small amount of blood with which to begin a major thoracotomy on a patient who had already lost a large amount.

Jim and Archie, whom I'd summoned urgently from Miraj, arrived while I was making my plea for donors. I paused and quickly explained the situation to the two of them. "Guys, this is very bad," I said. "We haven't got but half a pint of blood promised, and Joseph isn't due back from Bombay until tomorrow. The kid isn't going to make it that long."

Archie was fluent in Marathi, having been in Miraj for five years. He addressed the group directly and vehemently. They continued to shuffle and to drop their eyes. The father asked: "Is my son going to die?"

"Very likely, if you don't donate some blood."

"Then it is God's will."

I began to feel anger welling up. But Jim, an eternal optimist, suddenly grinned and broke in: "Hey, guys, I'm a universal donor," he said. "I can give blood and we won't even have to cross-match it." It then occurred to me that I was a universal donor, too, and that the patient was a universal recipient. He could accept all four blood types.

Archie, unfortunately, had been in India long enough to have contracted both hepatitis and malaria, so his blood would not be suitable. But we now had enough to proceed, if just barely. I drew a pint from Jim, and then Jim bled me in turn. Shivaji went last. With Jim and me still feeling mildly wobbly, we set about our tasks. Jim, a skillful orthopaedic surgeon, was the designated anesthesiologist (for lack of anyone trained in the specialty). He used the simple, time-honored method of opendrop ether with a face mask—though the job was complicated by the fact that the coughing patient was still on his side to try to keep the bleeding confined to the diseased lung. Once Dev was unconscious, Jim intubated his trachea and was able to block off the bleeding bronchus with a balloon at the end of the endotracheal tube.

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