In you we trust


(This short story is entirely a work of fiction.)

"Welcome to Charaka!", Dr. Suketu Jha said as he offered a handshake to Prakash. Prakash beamed as he took the doctor's hand and excitedly said, "Thank you sir!"

Dr. Jha's search had ended. Ever since the senior most technician of the dialysis unit of Bangalore's swanky and famous Charaka Hospital, Ramesh, had resigned to join one of the new standalone dialysis chains coming up in the city, the operations of the dialysis unit had suffered. What could two junior technicians do, after all? The number of patients also kept growing as Dr. Jha was a skilled and empathetic doctor, a rarity these days. Months of newspaper ads, checking with contacts, even unabashedly calling techs himself, yielded little success.

Then finally, almost out of nowhere, Dr. Jha saw an email in his inbox one evening after his usual rounds. The subject read, "Applicn. for Sr. Dialysis Tech. - 8 yrs exp". Dr. Jha chuckled as he took in the abbreviations. But 8 years experience looked tempting. He went over the resume. It was a typical technician's resume. Bad formatting, spelling mistakes, a pompous objective. One thing struck him however. 8 years in only 2 jobs. That was rare in this industry! Dr. Jha called Anu, his secretary, and asked her to schedule an interview.

It was almost 8 in the evening when he could finally leave his room. On the way out, he stopped by at the dialysis unit as usual. Four cases were going on. The two junior technicians were managing the unit. There were two nurses helping out. But Dr. Jha was never sure. He dreaded every call from the unit fearing the worst.  He checked with the staff if everything was ok. One patient's BP had dropped a bit. Dr. Jha advised that they reduce the ultrafiltration volume. One of the techs proudly said that they had already done that. Dr. Jha smiled and said, "Good!" Under his breath he muttered, "Wasn't it obvious?!" But he realized that he needed to handle these rookies with kid gloves.

As he made his way to the car park, Dr. Jha thought about how easily he had set up the unit about a year back. He had found a team of technicians who were available as a dialysis unit about six kilometers from where Charaka was located had closed down. Ramesh had been very good, very efficient and took complete responsibility leaving only the medical management to Dr. Jha. But when he was given an offer by the standalone chain that was being started at almost double the salary he was currently getting, Dr. Jha could do little to convince him to stay. He did not even make an effort to talk to the management of Charaka because he knew what they would say. Ever since Ramesh had left, his problems started. The junior fellows did not know even basic inventory management, patient scheduling and other book keeping. Dr. Jha had to spend a lot of time in the unit fixing things and guiding them.

"Let's hope this new guy is some good," he thought to himself as he got into his Honda City and headed home.

That evening as he opened his MacBook Pro to look for some information on uptodate.com about a particularly difficult post-transplant case where an IgA Nephropathy case had shown an increase in renal parameters, he saw an alert in his Google Reader page that was headlined, "The Lufkin Davita Bleach Murder Case: Opening Salvos". He opened the link and read with horror the accusations against a dialysis nurse in Texas state in the US of injecting bleach into some dialysis patients at a Davita dialysis center. Dr. Jha was appalled on reading the sequence of events. How could anyone do this? How could anyone betray the trust of a patient? There was some mention of a Davita conspiracy to implicate the nurse to cover up bad processes. Dr. Jha felt a shiver down his spine. What precautions do I have in place to prevent this kind of a thing from ever happening?

Was the nurse at fault? Was it the unit? Either scenario was scary. I should institute processes immediately to make sure the chlorine content of the RO water is checked every month. Why every month? Why not every week? This was a critical aspect of dialysis. In fact, I should have it done every day! What about the staff? How can I make sure that they do their job? One disgruntled staff member is enough to bring about disaster in our unit. Just one disgruntled staff member!

Dr. Jha then took a Restyl 0.25 mg. He needed some sleep. Everything would be ok, he reassured himself. Indians never feel so strongly about any thing. An Indian would never kill a patient. The Restyl began to act. An Indian would never kill a patient. An Indian would never kill a patient. The Restyl took over completely.

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"Good morning Anu!", Dr. Jha said as he entered his department. Anu had just got in and was surprised to see her boss come in so early. He looked quite excited. He quickly put his things in his room and dashed off towards the IP rooms on his daily rounds of the admitted patients. He had also found something to try for the troubling IgA Nephropathy case.

Dr. Jha hated for a transplant to fail. A transplant, he believed was the ultimate challenge in nephrology. It was the only real treatment, he felt. Dialysis - even daily - was at best a compromise. Yes, good, frequent, long duration dialysis did offer a good quality of life but it wasn't even close to the quality of life offered by a transplant. And then you had the whole act of donating an organ. This, he felt, was the ultimate donation anyone could ever make, the ultimate act of altruism. Dr. Jha would always have a one-on-one session with the donor before the transplant allaying any fears, giving strength and strongly praising the decision to donate. One of the main reasons he was very keen that every transplant succeeded, apart from the well-being of his patients, was that he did not want the donation to go in vain.

Dr. Jha made his way to the Transplant ICU where the IgA Nephropathy case was being kept. It was a young boy of about 28 years. Everything went well during the transplant. His mother had donated. The mother was fine, as expected. For about a month, everything was fine and then suddenly the creatinine started rising. Dr. Jha, the boy and his family, everyone was on tenterhooks. This wasn't a new occurrence for the doctor. He had handled rejections and worse in the past. Yet, with every case, there was this nervousness. The stakes, after all, were so high! For Dr. Jha, it was one of many transplants. For the patient however, this was his only shot at a normal life. His one chance. Dr. Jha realized this.

As he greeted the patient after donning the mandatory gown, mask, gloves and slippers, he said he was changing one of the drugs in his prescription and hopefully that should improve the kidney function. The patient understood. Transplants are a tricky business. You are never quite sure of what to do. The boy was aware of this and was happy to be in good hands. He trusted Dr. Jha completely.

By the time he completed his rounds of the other IP patients and returned to his room, it was around 11:30. He asked Anu for a cup of black tea and settled down at his table rummaging through the journals to read up a little more on one of the IP cases he had just seen.

"Sir, Prakash, dialysis technician, is here for an interview", Anu's voice announced on the phone.

"Send him in!"

In his preoccupation with the transplant case, Dr. Jha forgot to visit the dialysis unit and all about his problems with the understaffing. He looked up in anticipation as a short, lean and unassuming young guy, twenty five perhaps, asked to come in. Dr. Jha gestured him to come and sit just as his cell phone rang. Quickly muttering an apology to the caller, Dr. Jha focussed on the resume which the candidate gave him respectfully. It was the same resume that he had seen earlier. The same mistakes, the bad formatting, the wrong spellings. These things did not matter of course, as long as the guy knew his job well!

The interview lasted about 45 minutes. The doctor and technician took an instant liking for one another. Prakash knew dialysis. He was passionate about it. It was easy to see. Unlike many other technicians Dr. Jha had encountered in his career who had at best, a superficial understanding of dialysis, Prakash knew the concepts. About twenty minutes into the interview Dr. Jha had made up his mind to hire him. But he continued because it had been a long time since he had had an interesting discussion on the subject with someone of Prakash's background. More than anything, Prakash's enthusiasm intrigued the doctor. They discussed Kt/V, its merits and demerits, Peritoneal Dialysis, using high flux dialyzers, cross infections and much more. Towards the end, Prakash also felt the interview was going well and was quite confident of being hired.

Dr. Jha then broached the topic of the salary. Prakash's expectations were reasonable. He asked for about 25% more than what they were paying Ramesh and about 30% more than what he was being paid at his previous job. Prakash would serve his notice period of a month and then join Charaka.

"Welcome to Charaka!", Dr. Suketu Jha said as he offered a handshake to Prakash. Prakash beamed as he took the doctor's hand and excitedly said, "Thank you sir!"

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The month passed by quickly.

Prakash was there on the designated day at the dialysis unit at Charaka Hospital, all excited and ready to take charge. He went over to meet Dr. Jha first. Dr. Jha was getting ready to go on his rounds. Though Prakash would need to report at 7 a.m. every morning, on the first day he was asked to come at 9:30 so that he could be introduced to the rest of the staff. This was going to be a little tricky. Whenever someone from outside comes and joins a team in a superior position, there is always a risk of the existing members of the team feeling insecure, threatened and even being non-cooperative with the new leader.

Dr. Jha was aware of this. He first sat with Prakash and explained this to him. He counseled him on how to deal with each member of the staff, their strengths and weaknesses and how to slowly win each one's confidence. Dr. Jha mentally grinned and patted himself on the back. In a short span of time, he knew more about the dialysis unit staff than he had ever known about any of his direct reports!

The doctor led his hopefully-soon-to-be-trusted lieutenant to the unit and gestured for everyone to come to the nursing station. The staff collected quickly. They all respected the doctor and knew he had concerns regarding the unit. They were all trying to impress him. However, they realized, it hadn't been enough.

In chaste Kannada, the doctor began, "Hello friends, I am happy to introduce Mr. Prakash, the new Chief Dialysis Manager of our dialysis unit." He had picked up the language in his decade or so in the state quite well. It is important for doctors to speak the language of the patients. They can relate better. More than half of his patients were Kannadigas.

Some dialysis patients woke up to see what the fuss was all about. Some slept back. Some strained their ears to catch what Dr. Jha was saying. Any distraction is good enough when you're on dialysis!

"Prakash has many years of experience in running dialysis units. Prior to this, he was working in Sanjivani Hospital as Chief Dialysis Manager. Prakash will now lead the operations of the center. I will be working very closely with him to make sure that the transition will be smooth."

A machine sounded an alarm. One of the junior techs rushed off to press the Mute button. The patient had moved his hand to cause a kink in the tubes. The tech straightened the line and reset the alarm. He rejoined the group. The meeting continued.

"I thank you all for the co-operation you have given me in the last few weeks and am sure you will co-operate with Prakash in the same manner. I wish Prakash and all of you the best of luck in your work at this hospital. Thank you."

There was a light applause.

Dr. Jha asked Prakash to get himself familiar with the unit. He would finish off his rounds and join him. He would start transitioning all the responsibilities one by one to Prakash. Dr. Jha rushed to the IP rooms where his cases were admitted. The IgA Nephropathy case was doing much better. He wasn't fully all right though. The new drug had the desired effect. It took more than two weeks for them to see his values  return to normal. Those two weeks were very tense for the patient, his family and the doctor. There was a mild infection which they were treating now. That was also on the wane. Hopefully they would be able to discharge the patient in a few days.

Prakash started interacting with the technicians and nurses. He wanted to get a sense of how things were in the unit. He asked to be introduced to the patients. The junior techs took him around and started telling the patients who were on dialysis about Prakash. Some of them were asleep. Prakash signalled not to bother them. He knew that sleep was the best way someone could spend a session on dialysis. They came over to a bed where there was a pretty, young girl. She was awake reading a book. The techs introduced her to Prakash as Aparna madam. "This is the new Dialysis Manager", said one of the techs, "Prakash sir".

"Oh good", said Aparna, "now your work will become easier", she smiled and said to the junior techs. They all smiled back.

Aparna was on dialysis for the past four and half years. She was diagnosed with chronic kidney failure about five years back at the age of 24. Anyone would have been devastated with this sequence of events but not Aparna. She quickly gathered herself and fought to regain control of her life. She started working part time within a year of being on dialysis and she was now working full time. She had lost both her parents at a young age and only had a brother who stayed in the US with his family. They visited India rarely but kept in touch with her every week on phone. She usually came for her session in the third shift but today she was taking the day off to attend a family function and wanted to be done with it in the morning.

The techs moved to the nursing station and told Prakash that Aparna madam was their most active patient. She knew a lot about dialysis and would correct the mistakes they made not only in her case but also in other cases. Prakash raised an eyebrow. Correct mistakes in other cases as well? Hmmmm...

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Within a few weeks, everyone got to know that Prakash was very skilled. He could cannulate difficult cases with ease. He knew the machines inside out. He could handle complications also fairly well. He gained everyone's confidence.

Prakash took pride in his work. He was extremely confident about his abilities. Education-wise Prakash was like many other dialysis technicians - no graduation degree, only a diploma in Dialysis Technology. Yet, he was very skilled. Patients wanted only him to cannulate. They hardly felt any pain. He could cannulate in one attempt.

Cannulation is a tricky beast. Some people say it is a natural gift. Some people say it can be mastered by practice. Some people accuse it of being over-rated. Whatever it is, one thing is for sure - cannulation is the thing most dialysis patients fear like hell. Severe pain is one of the less damaging effects of a badly done cannulation. Worse things can also happen.

Prakash slowly took over the administration of the unit as well from Dr. Jha. He adroitly handled staff scheduling, patient scheduling, inventory, housekeeping - everything that needed to be done in the unit. The junior staff did not mind this at all. They recognized their limitations and were also happy that the burden of all these things was no longer on them.

Dr. Jha was a happy man! He could now focus on things he really needed to focus on, things he was meant to focus on.

One Friday evening, Aparna came in for her session. Of late, Aparna had also been impressed by Prakash's handling of the unit. She found that she got onto the session much sooner than before, could leave once her session was completed much sooner and overall the unit looked much cleaner and more organized than before.

It wasn't like this always though. She was coming to Charaka only because she stayed close by. She would not generally tolerate inefficiencies easily. But she had little choice given the distance other units were from her house. But now, things looked better. She was hoping Charaka would offer good quality dialysis now that they had a good technician in place.

Aparna got on to her bed and waited as the junior tech primed the dialyzer and the bloodlines. She had checked her weight herself and was calculating the weight gain. 3.5 kgs! Hmmmm, however much I restrict my fluid, I do not put on less than 3 kgs! What is the point in restricting?

Prakash came and wished her.

"How are you Aparna madam?"

"Fine, thank you, Prakash"

"How much weight gain today?"

"3.5 kgs"

"Hmmm, too much water?"

"No Prakash. I hardly drink any water."

"That's what all patients say madam! I wonder how the weight goes up so much then!"

Prakash laughed as he said that.

Aparna hated to be compared with 'all patients'. She was not one among 'all patients'. She knew her body and no one else did. She did not drink that much. She knew it. Who is this technician telling me all this bullshit?

She refrained from reacting however.

Prakash got ready to start the session. The junior tech who primed the line was assisting. Cannulation went on smoothly. Prakash connected the bloodlines and started dialysis. Within a minute or so, the Air Bubble Detector Alarm rang. Beep, beep, beep! Prakash reset the alarm. Very often these alarms are only transient alarms. A mere reset a few times does the trick.

Not this time. Beep, beep, beep! It went on.

Prakash noticed the venous chamber had become frothy. There was excess air in the system.

Beep, beep, beep, the noise continued.

Aparna was worried by now. Most alarms were always taken care of by resetting. What was this, Aparna wondered. She asked Prakash which alarm this was. Prakash ignored her. She persisted.

"One minute, madam."

Aparna waited.

Beep, beep, beep, the alarm nauseatingly continued.

Aparna asked the junior which alarm it was.

"Air detector, madam", the junior offered. He knew there was no point in hiding anything from this patient.

Aparna also got really worried now. This was the most dangerous alarm among all the alarms that could go off in a dialysis machine. Dialysis machines were designed to ensure that even a little amount of air did not enter the blood of a patient.There is an air bubble detector that is placed in the circuit just before the blood is returned to the patient. Any tiny droplet of air sets of an alarm and the blood is stopped. Only when the air is removed can the blood be returned.

Aparna kept a close watch on what Prakash was doing. She saw Prakash remove the line from the air detector. This would bypass the alarm without actually correcting the problem.

"No!", she yelled, "don't remove that!" Prakash instinctively put it back on hearing her. "It might be a false alarm", Prakash retorted.

"Its not. The venous chamber is full of bubbles! Check the connections to the dialyzer and the dialyzer caps. They might be lose." Aparna said.

In an instant Prakash knew that she was right. That could be the only reason. He immediately reached for the dialyzer. One of the connections to the bloodlines was loose. Air was entering into the system through that. Prakash immediately tightened the connection, inverted the dialyzer and hit the dialyser with his palm nudging the air to the top so that it could all accumulate inside the venous chamber. Within about five minutes, the air bubble detector alarm stopped and dialysis began.

Prakash was livid. The junior had not tightened the connections. This was a part of the priming process! How could he have not done it? He quickly completed the other formalities and asked the junior who had primed the kit to come into the ante-room that was behind the nursing station. The junior's face paled. Within a few seconds of him entering the ante-room, a loud slap was heard. The junior came running out of the room, hand on cheek, tears rolling down his cheeks and left the unit. The patients were all shocked. Aparna couldn't believe her eyes. She did not know what to do or say.

Silence enveloped the entire unit the rest of the evening. Prakash was still angry. The staff were all visibly shaken. The patients hoped they would have no complications that evening. Aparna couldn't think of anything else. She replayed the sequence of events in her mind again and again. She wondered if she could have handled the situation in a different way. She was convincing herself that she did what was right for her. If she had allowed Prakash to remove the line from the air detector, her life could be at risk.

Prakash came to close her session at the end of four hours. They did not say a word to each other. Another junior lead Aparna out after checking her weight. As she settled into the seat of her car, she thought to herself, "What just happened?" She had no clue. It was all like a blur. Like it never happened. It was too weird to have really happened.

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"I can't believe no one told you yet!", said Aparna. Dr. Jha's face was very serious. Aparna came to meet him before her session. It was a week since the incident had happened. Nothing was done about it. She came to Dr. Jha to check what he was going to do about the incident. No, not the alarm. Alarms happen all the time. Even air detector alarms. But a senior technician slapping a junior technician. That couldn't be allowed!

Dr. Jha asked when this had happened. "Exactly a week back. Last Friday. In the evening shift.", Aparna replied. Dr. Jha immediately understood. Of course no one would complain. Who would? The junior techs? The patients? Who would take on the mighty technician and risk his wrath?

"Aparna", Dr. Jha continued, "are you facing any problems in your dialysis?"

"No Doctor".

"Ok, then you forget about this. I will deal with it."

"But Doctor!"

"Don't worry. I will deal with it. I am telling you na!"

"Ok Doctor." Aparna got up to go to the unit and get started. As she was leaving the OP room, Prakash was entering. They avoided eye contact. The last two sessions had been similar. No eye contact. Prakash would avoid all conversation. Aparna also did not say a word. Nothing much changed inside the unit. The junior was back the very next day. Everything seemed normal.

Aparna wondered why no one had complained to the Doctor. Well, patients would definitely not complain. For one, they had nothing to do with it. And then, who wanted to upset the lead technician? But what about the staff? The staff were probably too scared to complain against their senior. He had all the power in the unit. Dr. Jha fully trusted him. The patients loved him. So, was nothing going to be done about this? Perhaps. Unless Dr. Jha puts his foot down.

Prakash entered the unit after about five minutes. He went and sat at the nursing station. Aparna was waiting for him to come and start the session. He got busy on the inventory register. After a couple of minutes, he called out to the junior tech who had assisted him last Friday. He whispered something in his ear. The junior looked surprised. He came over to Aparna's bed and said he was going to start the session as Prakash sir was busy. Aparna's heart became leaden. So this was what happened if you complained!

Luckily the session started without any problems and the cannulation wasn't bad either. But Aparna felt her eyes become heavy once the session was on and the tech had also moved away. She fought off her tears.

After a while Dr. Jha came on his rounds of the unit. Prakash accompanied him as he moved from bed to bed. When he came to Aparna's bed, there was no discussion about the incident or the complaint. After the session, Aparna went to his OP room but he had left. She was about to dial his cell phone on her way to the car. But she disconnected when she realized it was 9 in the night. What had the Doctor told Prakash?

She couldn't sleep until late that night. She kept thinking about the last one week. She was wondering if she had done anything wrong. Now that she had complained against Prakash, would he never cannulate her? Would she always be cannulated by the junior techs? What if she ran into complications during the session that couldn't be handled by the juniors? What if Prakash refused to help? Should she change her unit? The others were too far away.

Aparna called Dr. Jha next morning and asked him what he had told Prakash. Dr. Jha said he had sorted the matter. Prakash would control his temper and not slap anyone in the unit. "That's it? No punishment?", she asked.

"Aparna, this is not a school where we can punish students. I counseled him on how to behave with junior staff. After all he is very good at his work. A few rough edges for sure. But nothing that can't be corrected. How are you feeling?"

"Fine doctor. Thank you. Ok bye doctor." Aparna said as she hung up.

On the next session on Monday, Aparna dreaded what was going to happen as she walked towards the dialysis unit. When she went in Prakash was cannulating another patient. She checked her weight as usual and went over to her regular bed. After a few minutes Prakash came over to her and started the process of beginning dialysis. Aparna felt a little relieved. They did not speak anything. But at least he was starting her session.

The next session when she entered the unit Prakash greeted her and asked her how she felt. She smiled back and responded. Within a few more more sessions, both were normal. The past was forgotten, Aparna felt. In her own interest, she must be on good terms with Prakash. Let's face it, I need him more than he needs me.

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Aparna used to read up a lot about her condition. She also read up a lot about dialysis. She was a  member of an online forum of dialysis patients too where she would get a lot of information about the dialysis process and the various factors involved in it. Over the months she had developed a very good understanding of the concepts involved. She was completely on top of her dialysis settings and would insist that she dictate the parameters rather than the technicians.

Prakash, on the other hand, got all his dialysis knowledge from practice. For the past so many years, he had encountered many situations which helped him to handle most complications fairly well. However, his theoretical background was weak. The diploma he had done was like most other diplomas in the city. Theory was rarely taught. The students were simply expected to come to the unit and then learn the practical aspects of dialysis from the seniors. They did what the seniors did. If some senior learnt something the wrong way many generations back, chances are that several generations of dialysis technicians down the line were repeating the same mistake.

For the past few weeks, Aparna noticed something peculiar about an elderly male patient who used to generally be taken in the bed opposite to her on the same days as her, in the same shift as her. He would come in with barely a liter of extra fluid but about halfway into the session, he would get severe cramps. The technicians were simply not able to pull off even that minimal amount of fluid. This baffled even Prakash. Aparna had an idea. But she was wondering how she could tell Prakash.

Aparna knew exactly how Prakash would react. He was the kind of guy who would feel so belittled if someone else gave him an idea in his field of expertise that actually worked. It would be much worse if that someone was a patient. And even worse if Aparna gave that idea. Aparna realized this. But she couldn't let the patient suffer any more!

"Increase the conductivity!" she shouted out as Prakash was discussing the problem with the junior technicians while starting the man's session.

Everyone turned to look at her. Prakash's face turned red. The juniors turned to look at Prakash. The patient looked at Aparna and then at Prakash. Aparna regretted it instantly. What have I done?

Prakash burst out laughing. He shook his head in disbelief. There was silence all around. He did increase the conductivity however. He increased the Prescribed Sodium setting. The conductivity came up to about 14.5 in a few minutes. Prakash kept returning to the patient to check if he was cramping. He was doing quite well. The fluid was all successfully removed. For the first time. Aparna was also keeping an eye on the patient. She was happy to see that the fluid was removed as well. She knew what keeping extra fluid on meant. Prakash did not talk to Aparna that day. He closed her session. But did not say a word.

Prakash went home that night very dejected. Why didn't I think of that? There was nothing great in what she suggested. It was not a new medical discovery. It was the obvious solution. But still, why didn't I think of that? She is not even qualified in dialysis. She has no experience. She is only a patient. How did she think of that and why didn't I?

He recollected all the nice things patients said about him. They treated him like God. They brought gifts for him. He thought about all the times he thought of innovative solutions to the issues patients were having on dialysis and how he had relieved them of their problems. He kept picturing himself cannulating different patients. He remembered patients allowing only him to cannulate. It felt good. It felt good to have so many people look up to you. It felt good to have so many people revere you.

And then there was this patient. What did she think of herself? Who did she think she was? Telling me what to do! Look at her guts. The way she shouted out in front of everyone. She wanted to insult me. That was her only intention. She had no interest in the patient. All she wanted to do was to insult me. The bitch! She must be taught a lesson. A lesson she would never forget.

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Hepatitis C is a scourge in dialysis units today. Many patients become Hepatitis C positive a few years into dialysis. The indolent nature of the disease has caused not enough attention to be given to it. Medical proessionals are more focussed on immediate problems that dialysis patients face. A disease that takes about a decade to start showing clinical symptoms is not very high on the priority list of nephrologists.

Left untreated, the disease can cause Liver Cirrhosis, Liver Cancer and Liver Failure in about twenty years in non-dialysis patients. In dialysis patients this period is about ten years. Still, ten years is a long time for a dialysis patient.

Many dialysis patients do not even know about the danger of getting cross-infected with Hepatitis C in their dialysis units. It hits them only when they turn positive. Like other chronic conditions, this is also something that 'cannot happen to me'!

Despite all her knowledge about kidney disease Aparna was ignorant about Hepatitis C. All she knew was 'positive patients' had to dialyze in a separate area. She hadn't bothered to find out more about the disease. 'It cannot happen to me', was what she thought too.

One morning, as Prakash started Aparna's session, Aparna noticed him drawing a blood sample for an investigation. She had not asked for any test. Why was he drawing a sample, then? He asked Prakash. Prakash said he was dawing a sample for Hepatitis C testing. Aparna asked him why he was doing that when they had sent the sample in the first week of the month as usual and it was already negative.

Prakash was fumbling as he answered. He said something about some mistake being committed in the Reprocessing Unit, about some mix up happening, about her dialzyer being mistakenly reprocessed in the positive reprocessing machine.

Aparna was apalled. Though she did not know exactly what had happened, it sounded horrible. She had a very disturbed session that day. She started imagining all kinds of horrible things happening to her. The word 'positive' has a very negative connotation. Though people on dialysis who are Hepatitis C positive will very likely not be affected by the disease, a whole lot of other issues crop in.

Aparna got on to the internet and read up all she could about Hepatitis C in dialysis patients. The fact that there wouldn't be any symptoms for years offered no consolation. She had plans of living for long on dialysis and this could mess things up a lot. She started doubting Prakash's role in this. The guy probably hates me. He might have done this just to get back at me. But then she thought that may not be true. No one can fall to that level. Not even Prakash. He has an ego but he will not stoop to a level where he would play with someone's health.

The report came back negative. Aparna was relieved. However it was not all over yet. The Hepatitis C virus can be in a so-called incubation period for months. Every month, Aparna would have to undergo the test to make sure she has not turned positive. At least for another 4-6 months.

Aparna was quite disturbed with the recent turn of events. At the back of her mind she had this nagging doubt that this was done on purpose by Prakash. She wasn't convinced however. She thought no one could do such a thing. She was wondering if she should talk to Dr. Jha about this. She debated this for a while. Maybe Dr. Jha could do something about the virus in the incubation period if it was already there? Maybe some additional tests might help check on this? She decided to talk to him eventually.

Dr. Jha appeared quite unfazed when she talked to him. He offered rather blandly, "Aparna, let us not assume anything until we get a positive result."

Aparna got a little worked up.

"But Doctor, what if I have really been infected? What if the virus is in the incubation period?"

"I would strongly advise you not to stress yourself too much with this. Let us repeat the test every month and see."

Aparna was disappointed. Dr. Jha hadn't been very helpful.

That evening, while watching TV at home, her brother called her. For the first time in many months, she broke down. Her brother felt helpless. He wanted to help her but could do nothing. He was stuck in a job in the US and couldn't return to India for another year. After the call as well, she put her head in her pillow and cried bitterly for about an hour. She felt very lonely and desperately wanted some support. She felt it was totally unfair for her to deal with all this all by herself. All her friends had got married and had loving and caring husbands. Some even had kids. And here she was, all alone in this world having to deal with this disease. She had come to terms with the dialysis bit. But this whole new Hepatitis C angle to it left her very scared.

--------------------------

Prakash found Aparna very depressed these days on dialysis. He secretly seemed happy at her plight. Serves you right! Next time think twice before attempting to insult me. He recollected how he cooked up the whole story about the mistake in the reprocessing unit. He just wanted to scare her for a bit. After a few months, when the reports would consistently come out negative, she would be ok. So no harm was being done. At the same time, he felt he was only dispensing justice. She did it only to insult him. So, she needed to be taught a lesson. And anyways, it was not as if he had really infected her with the virus. So it was all ok.

Unfortunately, Prakash had horribly underestimated the mental trauma he was putting Aparna through.

Month after month, Aparna would dread the first week when the blood would be drawn. The next 24 hours would be absolute hell until the reports came back. There would be temporary relief for a couple of weeks and the countdown to the beginning of the month would start all over again. Many times, Aparna considered ending it all. She could bear it no more. However, every time, she fought those depressing thoughts and said to herself, "I have not turned positive yet, right? If I ever do, then we'll see." and got herself back on track.

It was about seven months since Prakash had first broken the news about the possible infection to her. It was the beginning of the month again. Prakash drew the sample and sent it to the lab. By now Aparna was also less anxious about the results. This had been going on for so many months now. And the result was always negative. The rest of the session was uneventful. She requested Prakash to call her as usual and let her know when the results came back and left for home.

The next morning, three results came from the lab and Prakash opened the envelopes one by one to check the values. One Hemoglobin was only 6.8. He made a mental note to let Dr. Jha know. His Erythropoietin probably needed to be increased. Another patient's Potassium was 6.5. Too much fruit! The next report was Aparna's. HCV Negative, he muttered as he opened the report. The report said Positive! Prakash was shocked. How could that be? How could she turn positive? That was all a prank! Her dialyzer was not mistakenly reprocessed in the positive machine!

He was convinced it was wrong. He called the lab and blasted them. He said they had probably mixed the samples with someone else's. The lab was defiant. "No way!", they said. He said he would be sending a repeat. "Sure!", they responded.

How would he tell Aparna this? He felt the ground slipping from beneath his feet. He started sweating profusely. He sat down on a chair and started thinking about what he should do. My career is finished. Aparna will definitely complain to Dr. Jha and the hospital. They will suspend me. No hospital will take me. What have I done?! He then regained composure and told himself, I haven't really done anything. Relax. I have not made any mistake. I did not reprocess Aparna's dialyzer in the positive machine.

The whole sequence of events caused him to believe, at the back of his mind, that he had actually done something wrong, that he had actually infected Aparna's dialyzer with the virus.

He decided that he would send a repeat sample. The problem however was how he would tell Aparna about this? He would not be able to take a sample without her knowing. Prakash decided that he would say that the earlier sample got spoilt due to faulty storage and they couldn't do the test.

Aparna came the next day and Prakash seemed unusually tense and in a hurry. Prakash told her that the sample they had drawn last time got spoilt and they would need to send it again. Aparna was too tired that day to react. "Sure", she said and the sample was sent. This time, Prakash called the lab and asked them to be very careful with the sample and give him an accurate result.

-------------------------

Dr. Jha looked at the report gravely. He then looked up and asked Prakash, "What exactly happened?"

Prakash replied, "Nothing sir. I was just playing a prank on Aparna madam. I promise, sir. Nothing like that happened. I take the utmost care to make sure these things don't happen. You know that na, sir?"

Dr. Jha said, "Yes, I know Prakash. I trust you completely. But do you realize what you have done? Aparna is not going to take this easy. She will create hell for you - and me! The police is not going to believe you when you say it was all only a prank."

"Police? Why police, sir? Why will the police get involved in a medical matter?"

"Well, it is no longer simply a medical matter. You told Aparna that a mistake was made and now she has turned positive. What else do you expect from her? What do you expect from anybody? Heck, even I would go to the police!"

Prakash was shocked. He did not know what to do or how to react. He was seeing his entire career and life being destroyed in front of his eyes for no fault of his and he could not do anything about it.

"When will she come next?"

"Tomorrow."

"Ask her to meet me when she comes."

The next day, Aparna knocked on Dr. Jha's door. "Come in", Dr. Jha beckoned.

"Sit down Aparna."

"Good morning Doctor!"

"How are you doing Aparna?"

"I am fine Doctor, thank you. Prakash said you wanted to meet me?"

"Yes. I wanted to meet you. So, Aparna, your Hepatitis C report has come positive. While I understand this might be disturbing for you, I must also tell you that this is not a very big thing. This disease takes 10, 15, sometimes 20 years for any symptoms to show up. And that is if we do not treat it. These days there are some very good treatments available and most probably we should be able to eliminate the virus."

Aparna was shocked. As Dr. Jha said the last few words, tears started rolling down her cheeks. She immediately pulled out a handkerchief and wiped them off.

The tears gave way to rage however.

"How did this happen Doctor?"

"Aparna, I know it sounds horrible but to tell you the truth, these things happen in dialysis units in our country. We have still not been able to eliminate cross infections. Whatever we do, patients invariably turn positive every now and then."

"No Dr. Jha. In my case it did not happen just like that. It was done intentionally. He wanted to take revenge. He wanted to teach me a lesson. You know that Doctor!"

"Aparna, you're being unreasonable now. I understand you are going through hell right now. Please take care of yourself. I know, right? Many patients turn positive. It is nothing that Prakash did." Dr. Jha did not want to mention the prank. It would not be right at this point, he thought.

"I am not going to take this lying down Doctor. No way!"

"I can only advise you Aparna. It is your decision after all. You need to take good care of yourself."

"Thanks Doctor. I will leave now."

Aparna got up and left.

A flood of emotions hit her. Anger, confusion, despair, frustration. Prakash has done this for sure. I will not let him get away with it. I will see this to its logical end.

The next day, Aparna sought an appointment with the CEO of Charaka Hospital, Dr. Raghunatha Doraisamy.

Dr. Doraisamy was a cardiologist with over tweny five years of practice. He had started Charaka Hospital about four years back. He was a very reputed doctor and Charaka became quite famous in a short span of time. He had a good circle of friends from among doctors and he enlisted quite a few of them to join his hospital over time.

Aparna explained the sequence of events to him. He gave her a patient hearing. At the end of it, he said, "Ma'am, I am very sorry that this happened to you. I assure you that I will enquire into this personally and get back to you."

He took down her telephone number. Aparna left with some hope that some action would be taken.

That afternoon Dr. Doraisamy called up Dr. Jha and requested him to come over to his office. Dr. Jha immediately guessed that it was about Aparna. He reached the CEO's office immediately. Dr. Doraisamy told him that Aparna had come that morning and complained about the technician in the dialysis unit. She accused him of wilfully infecting her with the Hepatitis C virus.

"What is the truth?", Dr. Doraisamy wanted to know.

"I know the boy, Doctor", said Dr. Jha. "He would never do such a thing. It was only a prank." Dr. Jha went on to explain the sequence of events to the CEO.

Dr. Doraisamy realized that something needed to be done. If at all Aparna went to the press, they would be in trouble. The press does not verify the facts. They would not bother with the reality that Heptitis C infections are common in dialysis units. He visualized the headline in the papers the next day, "Dialysis patients get Hepatitis C at Charaka".

"Can we fire the guy?", Dr. Doraisamy asked.

"We found him with great difficulty Doctor. He is very good at his work. We will find it very tough without him."

"Tough or impossible?"

"Very tough Doctor!"

"What do you suggest we do?"

"Give me some time Doctor. Let me think about it."

"Take until tomorrow Dr. Jha. But this girl is not going to keep quiet. We will need to show that we have done something."

"Sure Doctor."

Dr. Jha was at a loss. He could not lose Prakash. He also realized that they had to do something about it. What would satisfy Aparna without letting Prakash go?

--------------------------

It was around 9 a.m. about a week after Aparna had gone to meet the CEO of Charaka. Aparna's cell phone rang. It was Dr. Jha. Aparna had moved to another hospital which was much farther away from her house. Dr. Jha had called to tell her that the hospital had decided to conduct an internal inquiry into the whole episode. The inquiry would be conducted by a committee of three doctors. The committee did not include Dr. Jha. The committee would have to submit its report to the CEO within 4 weeks.

Aparna did not know what to make of it. A committee formed out of the doctors working in the hospital itself?! What would that yield? When she heard the names of the doctors, her concerns somewhat reduced because they were reputed in their fields. However, she was by no means sure that justice would be done at the end of the day. Yet, she thought it would be prudent to wait before taking any further action.

The committee spent the next few weeks talking to all concerned - Aparna, Prakash, Dr. Jha, the other staff at the unit. The four weeks passed by fast. The committee submitted an 18-page report to the CEO at the end of it. The summary was on expected lines. No evidence to prove that Prakash had willfully infected Aparna with the virus was found. Prakash confessed to playing a prank on Aparna by saying that there was a mix-up in the reprocessing unit. For this, he was severely reprimanded. He was given a 50% salary deduction for the next six months. Dr. Jha was also advised to get another technician on board quickly so that over-dependence on one person could be avoided.

Dr. Jha called Aparna and told her of the report. He put it as if Aparna had won the case! "50% salary penalty for Prakash!", Dr. Jha exclaimed when he called her. It sounded like Prakash was going to be hanged!

Aparna was disappointed. Though she hadn't expected much more from this whole exercise, the result meant the problem was not over. She would need to fight some more, if she could, of course.

Aparna went to Charaka the next day and met Dr. Jha. She told him she was not satisfied with the results of the inquiry. She strongly believed Prakash was responsible. 50% salary deduction for a while meant nothing. When Dr. Jha told her about the prank, it sounded ridiculous. A ploy to let him get away with a light sentence. She told Dr. Jha, "You don't realize what has happened Doctor. My life has been destroyed. And you all are simply covering up a crime committed by your staff." Dr. Jha reasoned with her saying, "Aparna, many patients turn positive in dialysis units. You are not the first and you will certainly not be the last!"

"I don't care about other patients, Doctor. How did Prakash know about this a whole seven months before the report came positive?"

Dr. Jha had a Eureka moment. "That's the key Aparna! Seven months! The HCV virus is in incubation for 4-6 months. This happened after seven months, you see! So, Prakash is innocent!"

"Those numbers are never exact. Dr. Jha. Six months, seven months. How different are they in medicine? You should know better than that! Whatever happens, I am going to see to it that Prakash is punished for what he has done to me."

"Aparna, I totally understand what you're going through. In your interest, let me advise you. Get on with your life. Let us start Anti-HCV treatment. Don't waste your time pursuing this case. No one can prove these things in medicine. Especially in India."

Aparna had read up a lot about HCV cross infections on the internet in the past few weeks. She realized that it would be difficult to prove these things beyond reasonable doubt. Still, she did not want to give up. She felt like Prakash had slapped her on her face and was getting away with it. Her independent thinking and upbringing did not allow her to give up so easily.

What were her options now? Going to the police? Going to a lawyer? Going to the Medical Council of India (MCI)? All three options seemed hopelessly strenuous, complicated and ineffective. She had no energy to go to the courts month after month testifying in the hope that she would win a case that had so much stacked against her.

For a dialysis patient, each day is a struggle. Merely going about her daily routine - cooking, work, housework, dialysis was a huge task. She could barely make it through her day unscathed. She simply wasn't ready for an additional burden of fighting for justice. She badly wanted Prakash to be given a much more severe punishment. More than the desire for justice, it was so that she wouldn't need to fight any more. She simply did not have the energy. Physically and mentally.

Aparna sat brooding in her TV room at home that evening wondering what to do. She wanted a way out. Just then her brother called.

"Apu, how are you?"

Aparna burst into tears. She was feeling very overwhelmed. She couldn't take it any more. She needed help.

"Apu, stop crying. I am coming home, Apu. We'll get you a transplant. I will give my kidney. Stop crying, please. I am coming home!"

Aparna suddenly felt a huge burden being taken off her shoulders. More than the fact that she would be getting a transplant, the whole thing about having someone look after her offered great relief. She wouldn't have to deal with this alone any more.

----------------------------------

Aparna got a transplant a couple of months after that call. The transplant was a success. She would not need dialysis any more. Her brother was a good match. Her brother and family had come down to Bangalore and took very good care of her. Her sister-in-law was very loving and she took care of Aparna like her own sister. In moments of weakness, she would tell Aparna that they would feel so guilty every time they talked to her over phone from the US. But their situation was so horrible that they had no choice. Luckily for them, there was a change in rules around that time and they could come back to India without losing the opportunity to go back when they wanted.

The family was now perfect. They had beautiful moments together. Within a year, Aparna, her brother and his family moved to the US. Aparna took up a job which wasn't too stressful. It kept her busy. She liked what she did. Her health kept good too.

Epilogue

About a year after they moved to the US, Aparna got an email from Dr. Jha. It read:

Dear Aparna,

Hope things are going well for you. I trust that you are taking good care of your health. I am sure your blood test values are well under control.

Aparna, I wanted to update you about an unfortunate incident that happened at Charaka recently. You remember the technician Prakash. Poor guy, he unfortunately had an accidental prick with a Hepatitis C positive patient's needle. This was about seven months back. He was a nervous wreck all these months. He would get himself tested every month. A couple of days back, his report came out positive.

Prakash was shocked. We had to relieve him of his duties immediately as Charaka does not allow positive employees to work. Luckily we have a couple of other technicians we hired a few months back who are also good.

Prakash has gone back to his village. Before going, he came to me one last time and said remorsefully,  "I guess my karma caught up with me Doctor. I still remember what I did to Aparna. I was so immature and foolish. More than foolish, I think I was plain evil. What I did was so wrong. I will never forgive myself for doing that. And what has happened to me serves me right. What else could I expect after what I did?"

I am writing this email to you to advise you not to harbor any rancor towards Prakash, Aparna. He has been punished enough for his misdeed.

Take care.

Sincerely,
Suketu Jha

A tear rolled down her cheek. She immediately wiped it off. Her brother caught her before that however. "What happened?", he asked. She showed the email to him.

"Serves the bastard right!" he exclaimed.

"No, don't say that." Aparna replied. "No one should get infected like that. No one. Not even Prakash!"

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