Unmatched – Lessons From The Lab

Ah Bombay! Or what we now call Mumbai. Home to myriad dreams, indomitable spirit, tall buildings, small shanties, more people than you thought possible and a very rare blood group called….what else? The Bombay Blood group.

Just like this megapolis, its public health system too has its own quirks. Run mainly by the MCGM, The Muncipal Corporation of Greater Mumbai, it reminds me of a giant anthill with a queen and numerous minions. The three queens of course are the three teaching hospitals, KEM, BYL Nair and LTMGH Sion, with Cooper hospital a recent (and hopefully  welcome) addition, the minions being the smaller peripheral hospitals located in distant suburbs lending succour to the local populace with quick reference facilities to `Big Momma` should the need be felt by the denizens of the staff. The JJ group of hospitals are of a world of their own and do not fall under the ambit of the MCGM.

Twenty years ago, young, foolish and newly married, I arrived at V N Desai hospital in Santacruz, which is one of the peripheral hospitals of the hallowed KEM, armed with an appointment letter (my first job! Yay!), a fancy title (Resident Pathologist), lots of enthusiasm and of course, zilch experience. Looking back, I now see the slight hint of desperation which resulted in my appointment, for the powers that were in the MCGM had been apparently unsuccessful in pinning down a pathologist to work in the derelict lab and had to settle for a green behind the ears rookie MBBS instead.

Enter ME! Brimming with the confidence of being able to group blood ( we had been doing it since pathology lab in phase two) and the ability to draw blood from human veins albeit with a bit of poking and prodding. The honorary pathologist in charge, the roly-poly jolly Dr. Kohli (I have still not been able to ascertain whether he is related to Virat) greeted me with an enthusiastic “ Aap jald se jald cross matching seekh lo, phir night duty kar lena”.`Night Duty`, these two loaded words were the first damper on my ebullient self(because as a newly- wed, the only night duty which sprang to mind…ahem..ahem), anyway, moving on, I had to face the rather onerous task of breaking this news to my then newly minted better half (he has gone a bit mouldy now), which further darkened his already dark brow.

After a few days of begging and pleading with the permanent lab staff (read rather snooty lab techs), I was gradually trained in the intricacies of cross matching blood by the motherly Mrs. Sukkawala, the Junior Scientific Officer. This was the only task worth any salt for a self- proclaimed pathologist as the lab had no histopathology section and the rest of the routine work like blood counts and sugar levels were automated. Now, before blood can be transfused, it must be cross matched and if you have any Amar Akbar Anthonyesque pictures in your head, get rid of them now or the said blood bank will lose its license before you can say `Robert`. The principle behind this is very simple. The surface of the RBCS carry an antigen depending on the blood group and these react with any antibodies present in the serum. This reaction if severe enough can cause blood to clump in the blood vessels leading to a potentially fatal condition.

Landsteiner, widely considered the father of blood grouping came up with the concept of four groups-A, B, AB and O depending upon the presence or absence of antigens on the surface of the RBCs. What is little known however is that the And B antigens have a common precursor called the H antigen. This is sometimes absent in certain individuals and though they present as O group clinically, they form a special category and must be transfused with blood from a similarly deficient individual otherwise resulting in a severe reaction. This special condition was discovered in 1952 in Bombay and named after the place of its discovery-`The Bombay Blood Group`. It is extremely rare and occurs in about 1 in 10000 individuals in the Indian subcontinent.

After about two weeks, Dr. Kohli had had enough and deciding that I had been sufficiently trained was ready to be unleashed on the unsuspecting population as the in charge of the blood bank. I had of course been brimming with the misplaced confidence of the ignorant since day one and was now fairly sure of the intricacies of cross matching and dispatching blood for transfusion should the need arise. In fact, I had carried out several dry runs during the day and had passed with flying colours. Heaving a sigh of relief, Dr Kohli was glad to make himself scarce and not go bump in the night anymore. Night duty thrice a week quickly became a way of life. If you saw the better half moping in the KEM corridors, you could be sure it was either a Monday, Wednesday or Friday.

The initial nervousness gradually gave way to genuine confidence and the nightly call of the attendants `RP Madam, cross match ` no longer sent a shiver but a pleasant thrill of anticipation down my spine. I no longer went bump in the lab but rather gained confidence that I could pick my way there blindfolded. Peering through the microscope looking keenly for freely floating or clumped RBCs lent a strange sense of fulfilment to the dark hours of the night. I felt as if I was making a small but real difference, a small cog in the giant wheel of health care.

And then there came a fateful night which stands out in my memory for furthering my education in a way no library ever had. The usual call of `RP Madam` had come and gone. A cross match was required for a patient who was to have a planned surgery ( though I never did fathom why a planned surgery needed to be carried out, in the struggling moonbeams misty light in the dead of night). The surgeons were keen to hone their skills, but could not proceed without said blood being available should the need arise, this much being spelt out for them. It was an O group sample and this meant a lot of hard work since O is the commonest of all the blood groups. A quick peek into the storage facility showed no less than twelve bags of O group blood. It could be a long night. I had my own rule of thumb when it came to centrifuging the samples from the stored blood. `Sign of Four` I called it. It was necessary because true to municipal equipment, the centrifuge machine had only four intact slots to put the samples into. Picking the first four samples, I set to work, sending a quick prayer heaven wards that one of these should prove to be a match and I could return to bed. Centrifugation normally took around half an hour or more and I was leaning back in the hopes of a nap when the phone shrilled in my ear, shattering the stillness of the night.

It was the surgery registrar, a little irascible, asking whether the cross match was done. `Not for another 40 minutes`, I matched his testy tone because I rather fancied myself  the local expert on dealing with testy surgeons (the husband being one). The first batch did not have a single match. I fetched a sigh from the soles of my shoes. No quick return to bed for me. I had just started work on the next lot when the big black phone gave tongue again. In sepulchral tones I conveyed the news of the failed cross match, only to be treated to rather ripe surgical language. The hour being too late and my energy levels too low, I decided that ignoring was the better part of valour and did not retaliate in my usual peppery fashion.

Forty desultory minutes later, the result was the same, the sample still remained single in unmatched glory. A bleak grey dawn peeping through the windows matched my mood. Another hour of this, and I would be hard pressed to brush my teeth, bed now a distant dream. Putting in the last four samples with flagging spirits, I was interrupted by a loud banging on the door of the lab. Opening the door at the crack of dawn in a deserted lab is not a good idea, but fatigue had brought with it a strange recklessness. I marched up to the door and opened it only to see the flushed face of the surgery houseman in what he believed was a righteous rage at being pulled from his `cutting` and packed off to the godforsaken lab to deal with an uppity pathologist who for reasons best known to her seemed hell bent on thwarting the wishes of the surgeons. I realised the futility of trying to reason with the unreasonable and let him in. With the patience of a kindergarten teacher trying to explain that two plus two equals four to a rather dull and disinterested five- year old, I showed him the slides with the clumped RBCs. He departed slightly less belligerent, muttering under his breath.

The sample I had seemed strangely reluctant to be matched and seemed to take pleasure in its single glory as was revealed by the last cross matches. Blood, blood and more blood but not a drop to spare! I thought I was onto something inexplicable and decided to take the matter to Dr. Kohli for clarification when I was interrupted again, this time by no less a person than the surgery registrar himself who had decided to climb off his high horse to give me a piece of his mind. I tried explaining the situation the best I could and showed him all my slides. But when he had the gall to suggest that one of the slides appeared normal with fewer clumps and that I should release the bag, my nerves already frayed at the edges gave way. I do not want to repeat the words that I used in that little altercation in polite company, suffice to say that he departed rather shell shocked with the single ominous word `complaint` on his lips.

Wearily, I sat down to write my report. I knew that it would have to be a detailed one as I would soon be summoned to explain my nightly doings.  Sure enough, by mid- morning I had to report to the superintendent`s office with Drs. Kohli and Moorjani peering at me beadily. Luckily my slides saved the day and they could do no more than peer even more beadily through the microscope before deciding that I had done well. Dr. Kohli thought that the sample merited a more thorough study than was possible at the hospital and it was summarily dispatched to KEM .

A little while later, I was vindicated when the report from the KEM lab revealed that the patient had the Bombay blood group and required transfusion under specialist supervision and the saga came to a close.

That night taught me much beyond arcane academia. It taught me the importance of being meticulous no matter what the job for in our profession, a life did literally depend on it. It taught me the importance of standing up for what I thought was right in spite of receiving flak. But, most importantly it taught me respect for the people who worked behind closed doors, away from the spotlights of glamour and accolades making magic in their own quiet ways.