Accompanying agony with equanimity

Sometimes, we walk a short distance before we realize that we have crossed a pivotal bridge in our lives. I had entered unchartered territory, a terra incognita, sometime in the late 1980s, but I did not yet know it by its true name: palliative care. I had not heard of this term back then, but unknowingly I had plunged headlong into it.

Little did I know that this incredible work had already made its way to India. Dr Luzito DeSouza, an onco-surgeon, had by now built the first hospice in the country: Shanti Avedna Sadan in Mumbai. I just hadn't heard about it. I was essentially treating physical pain, but while I did that, my patients also shared their stories and their suffering with me, equipping me with a new kind of insight that allowed me to consider and discover their internal worlds. Their stories were altering and shaping my own inner mindscape, propelling me to do what I could to ease their suffering.

There were lessons to be learnt every day; new territory to navigate. One morning as I walked into the operation theatre corridor several minutes before the official work hours commenced, I found a patient lying on a trolley sobbing hysterically. It was hard to tell how long she had been left like that. It suited the system for the ward staff on night duty, in their eagerness to go home, to transport patients needing surgery to the operation theatre much before their turn. However, sometimes the unfortunate patient would have to lie alone on their trolleys along corridors outside the operation theatre for more than an hour. Their families were certainly not allowed anywhere near them. It was a lonely kind of hell.

I approached the crying woman. As soon as I touched her arm, she clung to me and implored, 'Please, let me see my son once more. They brought me here before he arrived. I think I'm going to die during the operation and I will never get to see him again. Please help me see him just once.' It was a simple thing to roll the trolley out into the waiting area where the relatives were all huddled. I shall never forget the look on her face as she hugged her son.

In those days, pain was a constant spectre haunting corridors and hallways, wards and rooms. Hospitals, where pain was generally left untreated, were its playground. I imagine that the preoperative period must have been particularly hard for those in pain, especially when left to contend with their misery on their own. Occasionally, I did attempt to help, and gave them small doses of injectable morphine, and if the dose was not enough, I would give them some more a little later, as I had done for Babu.

This was not some ingenious method, but I suppose in some ways it was also new in our practice at that time. There was nothing unscientific about what I was doing. The small bolus of morphine that I gave could relieve pain and couldn't possibly cause any significant harm.

I had looked up a couple of books and had found that even when given intravenously, morphine takes time to cross into the brain cells, which is where it really works its special kind of magic. It could take fifteen minutes to half an hour for the drug to meander its way up the arteries and cross the blood–brain barrier (a protective network of blood vessels and cells that filters blood flowing to the brain). So, I would wait for about ten minutes or so before I gave a second dose, hypothesizing that even if I give two tiny doses, marginally exceeding what was strictly necessary, no harm would be done.

The practice of intravenous titration of morphine (or another opioid) against pain has become rather routine today in many palliative care centres in India. A morphine trial, as we call it, is a beauty to behold. Patients come in bent out of shape in pain. They are hooked up to the IV line and given small doses of morphine even as they report their pain on a scale they can relate to. The titration is complete when the patients report that the pain is under control to their satisfaction, and that becomes their magic number on the pain scale. This process does not take very long to hasten pain relief in any pain crisis. A patient can go from begging to be euthanized to feeling light and liberated from an unrelenting tide of pain.

I first came in contact with children suffering from leukaemia because I used to be called in to assist with an issue entirely unrelated to pain. Back then, central venous cannulation (placing a catheter in a large vein close to the heart) was not a commonly performed procedure, and not all anaesthesiologists would do it. So, when a child needed a central venous cannulation for aggressive chemotherapy, I would be roped in. It was then that I wandered into their world of pain for the first time. Dr Salim, the hematooncologist, would allow me to administer my technique of repeated small doses of injectable morphine to the children. I was not merely poking catheters into them; I became friends with these children because I was the one who could take away some of their pain and torment.

One day, I got called into the hospital at 3 a.m. in the morning. Dr Salim wanted my help with a child who had leukaemia. The boy was extremely ill and the doctor felt that as a last resort, he should try a particular chemotherapeutic agent for which I was required to do a central venous cannulation. I was hesitant considering the condition of the little boy, but I also thought it my duty to perform the procedure.

But when I approached the child, his father said, 'I will not let you touch him. There have been enough needles into him. I know he is dying; let him die

in peace. Take your needles away.'

His anger and indignation had a strange effect on me. I felt a flood of relief that I would not have to do the painful cannulation for the boy, who was in an incurable condition. I assured the father that I certainly understood and had no intention to poke any more needles into his son without his consent. His anger abated a little. 'If you can,' he said softly, 'give him something for the pain. That is the least we can do for him. I can't bear the thought of him dying in suffering like this.'

With Dr Salim's permission, I started my now tried-and trusted repetitive small dose technique. He had a bit of nausea at times, and to counter that I added an anti-emetic. I found that 3 milligrams of morphine into the vein would make him almost completely pain free for a few hours. I diluted morphine in a syringe so that every millilitre would be 3 milligrams, labelled the syringe and gave it to the nurse with instructions to give a millilitre whenever the child had pain.

Sadly, I did not know enough to give the next dose before the pain came on. It was only much later that I learnt that the subsequent dose could safely go in before the effect of the previous dose had worn off and prevent an episode of pain every few hours.

I started seeing the boy a couple of times every day. He would be quite chatty at times, talking to me about ordinary matters rather than about his disease or his pain. It made me immensely happy that I had enabled him to be in this state, to feel normal at least for a few hours. I held that warm, gratifying feeling in my heart.

A couple of days later when I visited him the little boy appeared to be very ill, but perked up enough to give me a slight smile. 'How are you?' I asked. 'I am quite okay now,' the boy said with another smile. He died an hour later. It was not sadness that took hold of me; it was fulfilment. In his inevitable passage towards death, I was able to satisfy the wish of the little boy's father that he would not go in anguish.

(Excerpted with permission from MR Rajagopal's Walk with the Weary; published by Aleph Book Company)