As the saying goes,“the third time’s the charm.” The first time I heard this, I felt disheartened. I couldn’t help thinking, “So I just failed once. Does that mean I’m going to need to fail again before I finally get it right?” 

Now, I’m beginning to think that a third time for the charm would be a good deal, especially in the case of a medical diagnosis. 

The beautiful thing about Indian hospitals is that they are always understaffed and overburdened with patients. The residents are on a constant lookout for exploitable human beings — those with any semblance to the medical profession, no matter how minute. It’s beautiful not only in a selfish sense but also in an educational sense. The selfish perspective is that I have plenty of opportunities to learn as a medical student. In the educational sense, it means that whenever I bump into a resident at the hospital, regardless of the reason for the happenstance, I will get drafted as a five-minute unpaid and uninsured intern.

And so, last year, when, on one occasion, I happened to enter the emergency department pushing a wheelchair on which my friend, minus one anterior cruciate ligament (ACL), was sitting, a resident pulled me away from my wheelchair to evaluate someone on another wheelchair who had just arrived. The resident told me to take a brief history of the patient before his blue surgical scrubs disappeared in a violent, epilepsy-inducing swarm of nurses, stretchers, patients and their attendants. 

I turned to my new wheelchair. I was expecting a confused, perhaps condescending scrutiny of my sweaty t-shirt and shorts, exposed hairy legs and football cleats. I wouldn’t have faulted the patient for wondering why a young, panting kid fresh off the football field was eyeing her meaningfully. I’d gotten that look once before while inserting a foley’s catheter into a man’s urethra before a resident explained to him that I was a medical student. And I hadn’t even been in sweaty shorts at that time. Still, they were shorts all the same.

My ego was grateful that the patient gave no such reaction, but that was only because she seemed disoriented to time, place and person, which of course made my job significantly harder. I asked the patient’s attendant what was wrong. The older lady, who it turned out was the patient’s mother-in-law, said that she had been having stomach pain for three days after her husband had died in an accident. I asked her where exactly the pain was, whether in the chest or abdomen. She said something in the Marwadi language that I didn’t catch and opened her hand as wide as possible before smothering it all over her chest and abdomen. I gave her an exasperated expression. After subsequent questioning, I managed to determine that the pain was in her epigastric region, she was 40 years old, and she also felt pain around her shoulders. She also had difficulty breathing and a history of hypertension. Thinking something along the lines of myocardial infarction (MI), I proudly presented my findings to the resident. 

The resident cut me off midway and said, “After her husband died, she didn’t eat anything for three days, and that led to gastritis.” She promptly walked away, leaving me in the dust with a dumb expression on my face. I felt both disgraced and betrayed: disgraced because I hadn’t even thought of the possibility of gastritis and betrayed because the resident had just tested me and proved me stupid for no apparent reason.

I walked back to my ACL-less human-wheelchair complex and leaned on the handle. My friend asked me what I had been up to. I told him I had gone to diagnose a patient. I didn’t bother mentioning that the diagnosis had been off by 180°.

Unsanctioned employment

A few hours ago, my father and I had walked through the doors of a Turkish Airlines airplane at the San Francisco airport before being greeted by yet another stereotypical, heavily made-up, textureless white-skinned flight attendant exuding so much fake enthusiasm that I couldn’t bring myself to outwardly acknowledge her false kindness due to my backwardness in expressing emotions. I ended up letting out something of a grunt accompanied by a grimace. 

That was when a thought struck me. Even though I was not technically a doctor yet, I had just passed the exams that certified me to be one, and I was now entering the bowels of an airtight capsule that would be cruising at 800 kilometers per hour thousands of feet above the ground with only a few centimeters of an aluminum alloy separating everyone from a low-pressure, -40° C environment. What if someone fell sick?

When I was young, or rather, relatively younger, I had developed a technique to stay happy that bypassed the interplay of destiny. When I wanted something from my parents and asked them for it, I kept rehearsing in my mind the classic scenario in which they would not agree under any circumstances. This left two possible outcomes. My parents would now say they were helping me build character, which was tantamount to their refusal to grant my request. That is how it played out 95% of the time. And in such cases, because I was expecting a refusal, I wouldn’t feel bad. On the other hand, if they agreed, I would feel elated since I had been expecting rejection. Either outcome was a win.

But I had forgotten this useful technique. So when the thought of someone falling sick came to my mind, I told myself it was just one of those … rare kinds of events that … rarely happened. That was where I went wrong. My childhood technique may not have circumvented fate, but had I called upon it, I would have been mentally prepared.

Two hours into the flight and one hour into one of the worst DC movies I had ever watched, my backseat TV screen paused. I felt almost relieved at being given a break from the horrendous action scene. A sign stating ‘announcement in progress’ popped up, and an air hostess asked over the speaker if there was a doctor on board. 

I looked at my father. He told me to go. I conveniently reminded him that technically I wasn’t a doctor yet. He rolled his eyes as I got up and moved toward the back of the plane, hobbling on my hastily put-on shoes amid the turbulence.

As I moved, my vision tunneled, and all the surrounding passengers in their seats blurred and stretched out to the sides as if I were nearing the limits of the space-time continuum. I could only see a scene of gathered people and flight attendants around one of the seats. That was when I had a feeling of enlightenment, and my eyes widened – male cabin crew members existed. I had never seen one before in India. Could it be that male cheerleaders also existed?

I told this rare specimen of a flight attendant that I was a medical student, and he shifted to the side to give me space to see the patient. I took a brief history of the patient, my mouth ejecting words encoded by my brain running on autopilot. On the other hand, my conscious mind was busy trying to analyze what I was feeling. Everything felt so surreal as if I were in a dream or a videogame. I couldn’t contemplate the stakes of what I was dealing with.

Formulating a diagnosis

The patient was male, had difficulty breathing and a diffuse chest pain radiating to his left shoulder and arm that had been gradually increasing since the time he got onto the flight. I sighed internally. That’s not a good sign. Why couldn’t it have been stomach pain or a headache? 

The good thing was that his age was 34 and he had no history of diabetes, hypertension or any similar pain in the past, all features inconsistent with ischemic heart disease. The bad thing was that his typical clinical features screamed of a myocardial infarction or, in layman’s terms, a heart attack. I knew from my emergency department experience that it could be gastritis or GERD (gastroesophageal reflux disease). I asked if he had any history of reflux, and he said he did.

That should have been a good sign since it pointed in the direction of GERD rather than a myocardial infarction. The only issue was that it would mean giving him a simple drug like pantoprazole to manage his stomach acidity. And the thought of giving pantoprazole to someone with clinical features that flashed a myocardial infarction sounded absurd. Right then, I knew that I wouldn’t be able to establish the patient’s diagnosis confidently. The evidence said that it wasn’t a heart attack, but the fear of incorrectly diagnosing him as a false negative loomed in my mind. 

The fact was, I just didn’t have enough clinical experience yet to make a call as to what was more likely, especially taking into account all the circumstances and the possible outcomes. Should I suggest giving him nitrates, as is given for a suspected myocardial infarction, or perhaps an emergency landing into a foreign country? I doubted an ECG would be available on board. Should I give him pantoprazole? Or maybe there was another possibility I hadn’t thought of again. But my most prominent thought was how on earth wasn’t another doctor on the flight coming to see the patient? During my clinical postings in the hospital, it was so consoling and reassuring to have a senior with me who could redeem all my mistakes. But here, in this situation, would I have to validate everything on my own?

The flight attendant told me they were thinking of moving the patient to the back of the plane and start giving him oxygen. I told them it was a good idea. And so our impromptu medical team got to work. While I took the man’s pulse, I asked him to tell me more about the pain and if it felt like a crushing sensation. He was Turkish, and his English wasn’t so good, but in words I could comprehend, he told me that the pain increased on breathing in. His pulse rate was elevated, around 110 beats per minute, and the forceful movements of his heightened respiratory rate was visible through his shirt.

I pulled the male flight attendant away from the patient and told him that it could be something mild like reflux, but there was a chance that it was a heart attack, even though it seemed unlikely. Again, the possibility of it being a myocardial infarction, however improbable it seemed, was a big fat cloud in my mind pushing away everything else. I was not confident enough to completely rule it out. I told him that we could give him pantoprazole and that we should check if there were nitrates on board the flight. He asked me if I had a medical license, to which I shook my head, but reminded him that pantoprazole at least was an over-the-counter drug even in the US. He nodded, said he’d try to find another doctor one last time, and made another announcement call.

All’s well that doesn’t end ill

A woman walked up to me and told me that the patient had a history of neck pain on his left side. I asked her politely who she was. She replied that she was the patient’s wife and a pharmacist by profession. She said that his condition might not be anything serious. I couldn’t help but notice how calm she seemed, even though it was her husband who was currently sick. She radiated maturity and rationality. I nodded to her in agreement, but I was worried that it could be angina, and perhaps we should consider sublingual nitroglycerin. She agreed with me and told the flight attendant as well, but he once again said that they couldn’t give drugs without it being administered by someone with a license. I wasn’t sure whether to feel relieved at the indirect implication that my assistance was no longer required or to be concerned that this was an obstacle I might need to tackle. I briefly wondered if it was possible for me to illegally prescribe a drug that might cause me to lose my license, even before obtaining a license. Would the US rules apply, the Indian rules or perhaps even the Turkish rules? Or maybe if the matter ended up in court, they would seek to determine which country our plane had been flying over the moment I gave the patient the nitrates?

I asked the patient if he was feeling better as I pondered my hypothetical legal battles in the back of my mind. He said he felt slight improvement.I wasn’t sure what exactly this new piece of information meant for my next line of management as it didn’t move the pointer along the scale of a battle between a myocardial infarction and GERD any further away from the more dire condition. 

I felt some of my uncertainty and fear dissipate when I saw the flight attendant come back with a doctor, who he claimed was Iranian. I felt a little irked at how long it had taken him to respond to the situation. It had been well over five minutes. And why had it taken him three announcements of a medical emergency to finally show up?

He asked what was wrong, and I chipped in with my evaluation. A 34-year-old male patient with shortness of breath and chest pain radiating to his left shoulder and arm. There was no history of diabetes, hypertension or similar episodes of pain in the past. There was a positive history of gastroesophageal reflux. Perhaps the doctor didn’t realize I had training in medicine. He didn’t seem to give my words much weight. He turned to the patient and asked the same questions I had, which, while it felt insulting, was also gratifying because it proved that I had at least been on the right track. But then he embarked on an entirely different line of thought.

He asked if the patient had been on flights before, to which the patient answered yes. Did he have a history of anxiety? The wife responded, “Occasionally, but he’s never had a panic attack”. The doctor told the flight attendants to remove the oxygen mask and moved closer to the patient. “ You don’t have a heart attack.” He said firmly. “I just need you to calm down. You’re having anxiety. You don’t need oxygen or any medicine. You’ll be just fine.”

He said some other things after that that I didn’t register because I was too busy feeling stupid once more. It was the second time I had been unable to rule out ischemic heart disease. The first time, it had been gastritis, and this time, it was … anxiety. Sure, I had guessed it probably wasn’t MI, but to rule out that deadly differential and come to a lame possibility like anxiety was something I would not have been able to do. I was reminded of the popular saying on the TV show House MD: “It’s never lupus.” However statistically improbable, perhaps I was in a similar predicament: “It’s never MI.”

As the Iranian doctor moved away, another late coming doctor approached and promptly disappeared upon hearing that the situation had been resolved. But I was too busy feeling dumb to mind his tardiness. 

The patient’s wife turned to me and thanked me. Her smile was bright, but unlike the air hostess before, it appeared earnest and genuine. I was so confused about how to respond, not feeling quite deserving of her gratitude, that I can no longer remember how I reacted. It was probably a mixture of an embarrassed head rub and a “no problem.” I wanted to reassure her by suggesting that she could tell me if there was any issue in the future, but I decided to let the more competent doctors handle that part.

As it turned out, I was feeling more responsible than I had realized. Another hour into the boring finale of my movie, I got up and asked the pharmacist if her husband was feeling better. She said he was and that he was sleeping at the back of the plane. She once again thanked me with the same insistence as she had done before. I’m not sure why, but this time, I accepted her appreciation with far more maturity. Perhaps it was because I felt I had, in some part, done my duty by responding to the request for medical assistance quickly and going to check up on him again.

I went back to my seat, no longer in the mood to finish the stupid movie. I told myself that I should try to sleep since I would be severely jetlagged back in India while having to start my internship the very next day. And then I realized how ironic it was that just a while back I had been thinking I would learn how to manage such patients in my internship and had encountered one at the very moment I was getting back to college to start it. If this was destiny, the responsible power was laughing at me.

But perhaps the third time, I’ll be able to produce the correct diagnosis with confidence.

The views expressed in this article are the author’s own and do not necessarily reflect Fair Observer’s editorial policy.