Hijab Page 2
The chief’s main duty was to oversee that the hospital staff followed the guidelines laid down by the state’s medical board and to sit down in monthly meetings with other department chiefs to talk about important sounding stuff, such as a five-year road map to make us a state-of-the-art facility in the state of Minnesota. The ‘overseeing’ part was more about working with Carla, the chief of patient services—a sixty-five-year-old Administrative Assistant who had memorized every by-law of the hospital. My job was to sign all the papers at places the stickered post-it arrows pointed.
The department of obstetrics and gynecology had three doctors: Radhika, Smith and a Pakistani by the name of Abdul Razak. Razak also had come to Amoka just like us, seeking a green card. He too had completed his residency along with us in New York. After doing their residencies in family medicine, Radhika and Razak had gone on to do a one-year fellowship to learn how to perform C-sections. Since this training licensed them to do Cesarean sections on their own, they both functioned as OBGYN specialists. Radhika was the town’s only female obstetrician. With Smith’s retirement around the corner, she was the uncrowned queen of that department.
Razak was married to Zeba, a very pretty Karachi girl. Srikantha used to tease them, ‘Razak, when I heard that you guys were from Pakistan, I had expected your wife to look like any other Begum. Nice catch, buddy. And Zeba, you have a fine taste for selection of your outfits. You remind me of Zulfiqar Ali Bhutto’s wife when she was young. Watch out, guys. Your Mullahs will order a Fatwa if they see you walking around, without a burqa.’ Razak and Zeba had a two-year-old girl, Reshma.
Razak had absolutely no interest in hospital administration. He mostly kept to himself and lived comfortably with his wife and daughter. His only complaint was that no halal meat was available in Amoka. He was surprised that despite the presence of so many Sanghaalis, there was no one selling it here.
The prospect of a green card looming large, added to the fact that we landed these ‘chief’ positions within two years of completing our Residency meant that we were having a good time. In terms of rank I was the boss to both Radhika and Srikantha. In meetings—when I used management jargon like ‘Healthcare Reform’, ‘Strategic Planning’, ‘Creative Destruction’ or ‘Affordable Care Act’—Radhika would joke with me, ‘Guru, we will be getting our green cards in a couple of years. You look like you are getting comfortable here. Listen to me, if your mom pairs you up with a nice-looking girl, just get married. Think of an exit plan from Amoka. Keep New York and Chicago in mind when you try to settle down permanently. You look like you are never going to leave this place.’
Those were happy times. We were cruising along, like a ship sailing on a calm sea, like an aircraft flying at thirty thousand feet.
3. The Original Sin
Fadhuma’s pain had worsened. I had ordered for some blood work and asked the nurse to give her four milligrams of morphine and was anxiously waiting for Radhika’s arrival. I was a bit nervous about my expected actions as an emergency physician if Fadhuma were to deliver in the emergency department. I remembered Radhika’s words—‘Things will go just fine if it were to be a normal vaginal delivery. Normal babies will “pop out” like slippery blobs with or without your help.’ However, I had an intuition that Fadhuma’s case wouldn’t be ‘normal’.
Dr Carlos Alvarez, another immigrant physician from Mexico was working the shift with me. It suddenly occurred to me that this was a good time to respond to Human Resource’s emails. I asked Carlos if he would mind keeping an eye on Fadhuma as she was my only patient. I told him, ‘She is thirty-nine weeks into her pregnancy. She has mild lower abdominal pain, these could be labour pains. She had a few contractions when she came in, but nothing now. The baby is doing fine. I have paged Radhika. She is on her way. There are some emails that I must respond to. I will be in my office. Call me if you need anything.’ I was surprised at my own voice when I signed my patient out to him. The breech presentation and Fadhuma’s obstinate opposition to C-section had conveniently slipped out of my mind. I went into my office before he could ask any questions. Perks of being the boss, I chuckled to myself.
I went inside my so-called office, which was only a wee-bit bigger than a fifty-six-inch TV box, and started going over my e-mails. I was a bit uneasy about delegating Fadhuma’s case to Carlos at a crucial moment. I consoled myself, since Carlos loves delivering babies, he might be better suited than me for this job.
One email caught my attention. It was from a certain address Abdhi.Abu-Bakr@yahoo.com and was forwarded to me by the hospital’s human resources department. Abdhi had complained against Radhika to the hospital. The email that started with the salutation ‘To whom it may concern’ could be paraphrased as: ‘My wife Rukhiya Abu-Bakr was admitted for delivery to the Amoka General Hospital on 20 June. This was our first baby. We were as excited about this delivery as we were anxious. Our family physician, Dr Mohammad Mohammad had told us all along the pregnancy that we had nothing to be concerned about. We were skeptical about having our first baby delivered in a small hospital like yours. But, at the end we had no choice as Rukhiya’s labour pains were so bad that driving to Minneapolis was impossible. As luck would have it, I wasn’t in town at that time. A few of our relatives had accompanied Rukhiya to the hospital. None of them could speak English. Apparently, Dr Radhika insisted on doing a C-section right away. The baby was delivered by C-section within fifteen minutes of Rukhiya’s arrival at the hospital. We feel that we were given no other options. As there were no interpreters around, we could not make out who said what to whom and when. Later, we spoke with Dr Mohammad Mohammad and he told us very clearly that this was an unnecessary surgery. Our culture does not support cutting the belly open and taking the baby out. If either the mother’s or the baby’s life is in danger, as the baby’s father I should be the one to make the call on who gets to live. We believe it is wrong to not have given us this choice. Rukhiya, amongst all people, didn’t want her baby to be delivered by C-section and this unfortunate event has made her go into severe depression. She is not letting the baby near her. We would like to request a meeting with the hospital board members or anyone else who can dispense justice for us.’
I was a bit surprised by this email. Abdhi sounded like a Sanghaali name and I felt it was impossible that he could have had this kind of command over the English language to surmise his thoughts into such an articulate complaint. Even if he did, he must have approached another doctor for an opinion.
I was surprised by the coincidence and timing of the events. Rukhiya had her C-section a month ago. Now Fadhuma is declining hers.
I tried calling Radhika on her mobile. She did not answer. I went out and checked on Fadhuma. She was somewhat calm. Morphine was doing its trick.
I went to my office and looked up Rukhiya Abu-Bakr’s records in the computer. Twenty-four-year old Rukhiya had recently immigrated to Amoka as a Sanghaali refugee. She had checked into the emergency department with labour pains on 20 June at 4:10 in the morning. The emergency physician who saw her had immediately sought expert help by paging Radhika and had asked her to come to the hospital immediately. According to Radhika’s notes, Rukhiya had severe abdominal pain. The fetal heart rate was very irregular with very little variability indicating fetal distress. She was very clear in her documentation: ‘Family was explained of imminent danger to mother and baby including but not limited to fetal and maternal death at the worst.’ I chuckled at the use of language—‘not limited to fetal and maternal death’? Can there be anything worse?
She had also documented that since the hospital’s interpreter was not around, she had used interpreter services over the phone. Rukhiya was accompanied by her mother and a couple of young men who had identified themselves as her cousins. These two could speak spotty English and had apparently threatened Radhika that if she did any kind of surgery on Rukhiya, people would die! Scared by their words, Radhika had summoned the hospital’s security and had them escorted out, before performing
the C-section. She had made a note, ‘Due to an anatomical distortion of patient’s genitals, a vaginal delivery is unlikely.’ This sentence made me wonder for a moment, but I did not think too much about it and made a mental note to ask Radhika once she arrived.
I felt that anyone in Radhika’s place would have performed a C-section on Rukhiya. Since this was beyond my expertise, I thought of showing this complaint to Smith or Razak from the same department and getting a courtesy review from them. I hoped that they would agree with me and officially certify that Radhika had acted in the best interest of the patient. I forwarded the relevant documents to Smith and Razak and a copy to Radhika as well. I needed to send a response to Abdhi immediately.
In hospital administration, managing such complaints is an art by itself. All these shenanigans of patients complaining about doctors and their care were something that neither Radhika nor I was familiar with before coming to America. Once here, I had learnt to respond to our patients who complained about trivial things like non-availability of cable television in the waiting rooms. My response would invariably start with, ‘The hospital apologizes for not meeting your expectations.’ Patients and their relatives always would like to watch their favourite show on cable television in the waiting rooms, but the Amoka General Hospital was operating in ‘red’ every year and we had no money to entertain our patrons. However, I could not directly tell them so. I had to use my administrative skills to communicate this message tactfully. If my answer was a firm ‘no’ I would lose all my ‘sniffles’, ‘sore throats’, and ‘cuts’ to the hospital next town. At the same time, I could never convince the hospital’s financial officer why we needed a nice TV with satellite or cable connection in waiting rooms to attract our customers. The only solution that I had for this was to say sorry and apologize.
I therefore apologized to everyone with no exception whatsoever with a hackneyed ‘sorry’. I used this ‘sorry’ word so much that the word had lost its meaning. Both the apology monger and the giver were aware of this. It had turned into a ritual: they complained, and I responded with an apology letter!
I did the same with Abdhi’s complaint. After the usual ‘sorry’, I wrote, ‘We regret the inconvenience. Your complaint has been forwarded to our hospital review committee. We will get back to you after the concerned personnel review your case.’
What surprised me was that Radhika had never talked about Rukhiya’s case with us. While the patient privacy laws prohibit discussing our patients’ histories outside work, it hadn’t really prevented us from our dinner table gossip about ‘interesting cases’. My stories from the emergency department were always the best. They spanned from the unbelievable to the ridiculous. For instance, the story of a man who had come holding one end of an iron rod with the other end speared into his chest, or that of a blonde girl who couldn’t stop grinning after sudden detumescence with her boyfriend in tow. They were apparently trying a brand-new Kamasutra position when her ‘dude had broken his dick’. She had splinted his bruised, limp manhood with two plastic knives and a rubber band and had brought him in.
Radhika would invariably say, ‘Man, your stories are always dirty’ and would laugh hysterically. But as far as I could remember, Radhika had never raised Rukhiya’s topic either at home or at the hospital. I thought of asking her, ‘What else do you gossip about?’ I wondered why she had not spoken with me about it. I started reading Rukhiya’s records all over again.
Just then Radhika stormed into the hospital, after hurriedly parking her car in the parking lot. She poured herself a cup of coffee from the coffee maker. She was drinking the stale coffee while reading Fadhuma’s records ‘Hasn’t Duniya come in yet?’ she turned towards me and asked. I could sense some unrest in her voice.
‘She may be here at any moment. I’ve sent word for her.’
Duniya is the hospital’s Sanghaali interpreter. It has been twelve years since she left Sanghaala and immigrated to Amoka. She is about twenty-five years old. Since she attended high school in Amoka, she spoke English very well. This job was especially created for her at the hospital to meet the needs of the growing Sanghaali community. She also worked part-time jobs at places like Amoka’s paper mill, chicken farm, and packaging as an interpreter. She was the only interpreter for all of Amoka’s Sanghaali community. At times when she was unavailable, we used interpreter services on telephone or via Skype. My question in English would get interpreted on the computer screen and the answer would be delivered back in English. Sometimes we had live interpreters on screen; sometimes we only heard voices. Several times these faceless voices consoled the patients more than me and my Medicine. We could sense jitters in their voices and see sweat on their foreheads when we couldn’t get any interpreters; especially if the telephone lines did not work or if the Skype connection was down, then all the assurances that I gave came to no avail and with the refrain of ‘Interpreter, interpreter’, they panicked until they could see another Sanghaali face or hear another Sanghaali voice. This was a new experience for someone like me who firmly believed that a doctor is someone who saved lives by prescribing drugs.
‘I read Rukhiya’s husband’s complaint,’ Radhika said looking at her phone. Radhika had already read the email that I had sent just five minutes ago. I thanked these smartphones silently in my mind. I didn’t say anything but gave her a puzzled look.
‘Guru, have you seen her records?’ she sounded scared.
‘Don’t be scared Radhika. You have done your job. You’ll not be in any trouble. Anyone in your place would do the same. I’ve sent the records to Razak and Smith for review. This is only to appease the clients. I’m certain their opinion would be no different from mine.’
‘I hope so. Don’t you ever try to help anyone. Seriously. You will land yourself in deep trouble. God knows why these Sanghaalis are so rabidly against C-sections! Fadhuma says no to C-section too, doesn’t she? She is a breech. She will never be able to pop that baby out. She insists that I turn the baby downside up. Apparently, her mom did this to her sister in some refugee camp in Kenya and claims that the “baby came out just fine”. This is America. No real doctor does this here, especially at full term! In fact, it is against the law in some states. Now, what kind of antics should I pull off to get this baby delivered?’
Babies naturally settle into a head-down position which we call vertex presentation and come out with their heads leading. If by the ninth month the baby isn’t ‘vertex’, there is a chance to turn it ‘downside up’, by gently squeezing and turning the baby from outside. This is called ‘External Cephalic Version’ in medical jargon. This is the technique that Fadhuma was referring to. It was Radhika’s opinion that using this technique in her case was not only difficult but extremely dangerous. I offered my advice, ‘Why don’t you send her to the University and wash your hands off?’ Since Amoka was a rural hospital with no specialty care, we often sent our patients to the University Hospital in Minneapolis. Radhika said, ‘Guru, we can send patients to the University when we have complications or when we cannot absolutely handle them. There is nothing that they will do there that I can’t. After all, this is a simple C-section. If we send her to the University, folks there will raise a ruckus and complain to the government that we are dumping our cases on them. The problem is not that we can’t do it here, but convincing Fadhuma of getting it done. Our hospital has a team of three gynecologists, social workers and interpreters. We should work on finding a way to convince her.’
‘Why is this a problem now? Weren’t Sanghaalis living here even before we came here? Didn’t doctors perform C-section before you?’
‘This problem has been there for long. I’m not aware of the reasons. There has been a deluge of three thousand Sanghaali refugees to Minnesota this year. Fadhuma and Rukhiya have also arrived this year. Perhaps, they are not familiar with the culture here. And it is very difficult to make them understand.’
‘Why don’t you ask Smith? He has been here at Amoka for a long time.’
Not having any comment to offer, I said ‘Good luck’.
Duniya came in, walked over to Fadhuma and wished her, ‘Assalam Walekum.’ She, poured two cups of coffee, for both of them, and sat next to Fadhuma. She looked at me, ‘Doctor, good morning. Kahaani is playing in Regal Cinemas at Minneapolis. Have you seen the movie? Very nice movie, Vidya Balan is pregnant in the movie, kind of like this.’ I didn’t know what to say about the Bollywood obsession of these Sanghaali girls. I remained quiet knowing that this was not the time to talk about Kahaani.
Radhika said disapprovingly of Duniya’s liberty in the department, ‘Guru, you are a bit too easy on these people.’ And went to Duniya and told her curtly, ‘Fadhuma is not allowed to eat or drink anything till I examine her. Duniya, you are supposed to know this.’ Duniya and Fadhuma looked at each other, talked to themselves in Sanghaali, and started giggling.
Radhika said, ‘Duniya, your job is to interpret what I say, not to make fun of me.’ They both appeared a bit stunned. Despite Radhika closing the door behind her, I could hear the conversation quite clearly.
‘Fadhuma, I’ve told you very clearly before that you need a C-section. The baby is breech. We are not even sure whether your earlier three deliveries were normal.’
Duniya was interpreting Fadhuma’s responses into English, ‘I’ve told you before. My first three were normal deliveries. I’ve told this to the other doctor too. The scar you see on my belly is because I had a tumor taken out.’
‘Letting you have a natural delivery poses significant danger to the baby. And to you too,’ Radhika told her directly and clearly.
Fadhuma responded, and Duniya interpreted, ‘There is no danger to the baby. I can feel the baby move in my belly very clearly. My mother had fourteen babies and there were all kinds of deliveries—feet first, hands down, and I was told my twin sister and I were hugging each other and refused to come out. My grandmother delivered us. No surgery.’