Complete Analysis of the controversial book 10cc by anonymous writer Dr. Ram Narayan Sharma

10cc

10cc is a novel⁷ on drug abuse⁸ by medical doctors¹³ written by Dr Ram Narayan Sharma and published first in august 2010. 10cc refers to the 10cc syringe⁴, i.e. a syringe with the capacity of holding 10 ml of a liquid, used mostly for delivering Intravenous²⁹ reconstituted drugs¹¹ like antibiotics¹². Reconstituted drugs are the one originally in powder form and to be dissolved in NS³⁷ or sterile water before injecting. Novel is written in dark comedy⁹ manner and reflects attitude³⁸ of young doctors in India¹⁰. The novel portrays beginning of a doctor in medical world with no ideals.

Publication history

It was first published in august 2011 by Power publishers, India. After the contract expired, it was published on the Amazon and is now available worldwide.

Naming of the novel

Antagonist²¹ in this novel, Dr Doshi, is a respected cardiologist²² but addicted to a sedative²³ ‘midazolam²⁸’. He prescribes midazolam 2 vials²⁴ to each patient²⁵ on a half torn prescription²⁶ so as not to allow the name of hospital²⁷ visible on prescription and stocks the vials. Whenever he needs to go high, he takes the drug in higher doses, up to 10ml sometimes. Doshi injects patients with air instead midazolam they have bought, saying ‘even if 100ml air is given intravenously, nothing happens¹⁹’. The icon³⁰ of a syringe as a means to get rid of ailments³¹ is degraded to the means of going high while working in an ICU⁴⁸, and that by a doctor. Sharma believes it to be the fitting tribute to today’s medical practices where games like ‘drunk doctor’ are being played⁴⁷.

Plot

Set in year 2007 in rural India, the novel criticises³² the entire Indian medical system³³ keeping the antagonist as the highest degradation of the once most noble of all professions.

Protagonist²⁰ is a young doctor whose name is not disclosed in the novel. He is referred as ‘he’. ‘He’ is an internist, smoker, drinker and good just in theory. He has very little experience of working in a hospital. He uses influence of his friend Sid to join the busiest hospital with an ICCU in town and get appointed in evening duty as a doctor. He works in his collage hospital in morning. The hospital is in an old crumbling villa infested with mice and rats and is extremely dirty. The hospital management is seen by mam, wife of Dr Doshi, the antagonist. Mam is dumb but sexy and protagonist yearns for her. In due course of time protagonist finds Dr Doshi doing weird things which are described by staff as done due to overwork. He soon finds out that Dr Doshi is addicted to a sedative ‘midazolam’. Doshi makes the patients buy the drug in the name of emergency⁴³ and abuses it. Protagonist finds out that all the staff and few patients are aware of this.

Within few days of this discovery Sid switches hospital that pays more. Antagonist keeps working in the un-sanitized hospital with another electropath¹⁴ doctor Kaate, dumb nurses and underperforming machines. Departure of Sid widens his responsibilities and he goes on learning quickly. He asks Manoj, a friend of his to join hospital but Manoj leaves within a month. Kaate departs after an emergency turned bad and He is faced with influx of patients while Dr Doshi keeps working in the hospital in inebriated state. Irresponsible sweepers and an underage exhausted nurse allegedly in love with Kaate makes his work even harder. He demands an extra nurse to mam instead of another doctor and gets a young, sexy and hopelessly dumb teen pseudo-nurse.

Though feeling bad for getting a useless nurse, Kamini, He is attracted to her and her tiffin which she spares for him. He starts flirting with her and finding it convenient for reviving less thrashing, Kamini starts showing interest. During this time He works tirelessly in hospital and confronts various kinds of patients and peoples. His notion of the hospital as a nightmarish place keeps rising, aided by increasing stupor induced deeds by Dr Doshi until his breakdown after helping a poor family. He decides to leave the hospital happily but thinks He is missing something. He finds out what He was missing at the end of the book.

Style

Dr Sharma was deeply inspired by ‘Catch22³⁵’ of Joseph Heller³⁶ which he was reading at the time of his internship. He witnessed the humour in serious hospital setting and noticed the ugly things which run in doctor’s world. So he started using the facts and blending the story in. The incidence of using the two contradictory articles on same website where half of the writers-researchers are same is one of the examples.²

Protagonist is not named at all in novel. He represents all the young medical students who are on the brink of losing their innocence and ready to carry on the legacy of rotten medical system of our age.

Two minds. Protagonist constantly feels tug of war with what he calls his sane and insane mind. In the end when protagonist decides to write a novel the sane one starts holding him back while insane one encourages him. This raises issue of whether it’s sane to be the part of the system and live happily or expose its true nature and break it in order to try to get something better.

The novel is straight in chronological order except prologue⁴⁹ and epilogue⁵⁰ and occasional flashbacks going in protagonist’s mind, protagonist getting reminders from his mentors and his interactions with friends.

Late night messaging between protagonist and Kamini is typical of youngsters since reliance³⁴ dropped the messaging rates in past forcing other cellular provider companies to do the same.

All the young characters say ‘yeah’ while the older says ‘yes’.

Major themes

The novel delves on youngsters thinking that ‘nothing can be done in or against the system’ and subsequent depression it burdens them. It’s kind of social dilemma, whether to report irregularities or just put a blind eye to it, pretending everything is normal. Protagonist has almost everything. A good family, doctor’s degree, knowledge, post in ICCU and subsequent experience after getting exposure, pay enough for himself for time being, a flirting nurse and a ‘happy meal facility’. But still He is restless, seeking something not knowing it is and smoking instead of trying to look for it. He finds it at the last moments of novel. He hates the system and still knows He is going to be sucked in it as noticed after the dialogue with the MR in chapter 23. His acceptance that ‘nothing can be done against Doshi’ sparks another way to deal with the situation when a former patient says ‘you came out to be too pessimistic.’ He ends up finding a way in the end.

For most of the events he has an alternate satirical dialogue or cuss word ready which he says in his mind. Like adding ‘bitch’ in mind after ‘yeah’ when he doesn’t agree to something but has to do it nonetheless.

Despair. Protagonist expects ICCU to be grand one but has to work there against his heart as he has no alternative. Dr Doshi was deemed brilliant and he notices that too. But the dopiness of Doshi along with suffering and anguish caused to patients and their relatives makes him sad. He wants to get rich quickly, but knows it takes time. He feels he can’t give time for his friends. He starts buying packet of cigarette for night instead one or twos he was used to. Lot of ‘great’ things are promised to our youngsters, but when seeing from close quarters everything loses its glamour seeing them reduced to lower levels.

Kamini, the young nurse with dubious past and many boyfriends, starts flirting with the protagonist in order to get away from thrashing she receives for incompetence in work and starts coming to hospital with his favourite snacks. Protagonist just wants to fuck her and finding plans not working, loses interest.

Doshi’s family doesn’t spare any chance in exploiting the genius after spending years in poverty. Instead of helping the needy people in spite of themselves being poor for a long time they want money from each and every corner of medical field like selling out-dated drugs. And they get away with that using money, influence and lawyers. They even appoint staff with no knowledge and experience because they work on low wages. They do not repair important machines like medical monitors⁴² and generators⁴⁴.

Issues raised

Plenty of issues regarding medical care and social problems in India are raised in this novel like

Addiction among the doctors – both antagonist and protagonists are addicts along with other characters like Sid and Kaate. They are drunk sometimes on duty. Number of addict doctors is on rise and it had started interfering with their duties^{40, 46}.
Neglecting government authorities – government watchdog authorities are not keen on keeping watch on private hospitals especially in rural areas and other healthcare institutions like PHCs. Undertrained staff is appointed at many hospitals. Authorities make occasional show of raids and everything gets back the way it was in few days. ⁴¹
Costly treatment – though for many people relatives fighting over bills of few thousands will sound shaky, but the story is set in ’07, in town of Yavatmal in vidarbha⁵¹ region, place of 1/3 of farmer suicides in ’06 and ’07 in vidarbha¹⁵. And comparing with the ‘facilities’ in hospital, it’s too much for the people around there.
Attacks on doctors – due to politically aspired goons, negligence from doctors and delay in treatment, attacks on doctors are more frequent in India. A brief mention of a mob beating an MO and throwing table on him is in ch3 as ‘girl bitten by snake died’ and another in ch 34, reasons are inability to control crowd in time, lack of infrastructure and serious staff.⁵²
Domestic violence⁵³ – a woman getting unconscious during beating and the running patients in ch 18 and 19 show that the women in India are still abused and few of the events are reported. And worse, women have greater participation in abusing other women.
Use of bizarre things to go high – traditional liquor, tobacco and drugs are lagging behind as doctors and non-doctors are experimenting with prescription drugs and making ‘cocktail drugs’⁴⁶ and other things like sanitizers⁴⁵, whiteners⁴⁵ as mentioned in ch 10.
Corruption in medical companies – in protagonist’s confrontation with MR, protagonist gets small idea of working of pharmaceuticals. Lot of references like costly medicines instead cheaper ones like ranitidine are also scattered throughout the book.⁵⁴ See the reference for rise in price by 1000% and company owner’s remark. This is throwing people towards bankruptcy⁵⁶.
This book is also shows light on ‘medical humanities.’¹⁷

Medical humanities is an interdisciplinary field of medicine which includes the humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice. The book shows pain of patients and relatives, as well as making of a doctor and educating young doctors about dark side of addiction.

Doctors symbol – whether it is caduceus or Asclepius rod? And from where they are derived? Which one is correct? Attempt to answer these questions in satirical way is be seen in this book. Mindless copying of caduceus for doctor’s symbol is subject of widespread debate³.
Confusing data – we live in the scientific world. But the scientific data, instead encouraging the knowledge, is misleading people and working in favour of pharmaceutical companies. It is explained best when protagonist wants to find information whether cheaper heparin or costly fractioned heparin is best for patients and gets extremely confused seeing two articles on same website. 5 of the researchers-writer are same in both articles giving apposite views using soothing words like ‘No statistically significant difference was observed when the efficacy and safety of low-molecular weight heparins were compared with those of unfractionated heparin. A cost-effectiveness analysis of low-molecular weight heparins versus unfractionated heparin must be done urgently to establish more firmly the place of low-molecular weight heparins in the management of unstable angina.¹⁸’ And ‘Enoxaparin appears to be superior in efficacy to UFH and similar to UFH in safety. No difference in costs was detected in this study. The greater inhibition of platelet aggregation observed in the case of UFH compared to enoxaparin indicates that there may be more bleeding complications with UFH².’ It was stated in first trial that drug ‘enoxaparin’ containing trials were not taken in consideration. So does that means one should go for enoxaparin instead of other low molecular weight heparins or undergo another trial for efficacy of un-fractioned heparin and enoxaparin which was not covered in meta-analysis or prescribe as one wishes or what the pharmaceutical wishes? Is costly fractioned heparins are really better than un-fractioned heparin? And most important, who is the authority responsible for taking final decision on making a drug prescription protocol and what is its stance on this confusion. Bored after thinking for some time, protagonist decides to goes to smoke, feeling nothing is possible to do against it.

Such incidences give rise to quotes like “Statistics are like a bikini. What they reveal is suggestive, but what they conceal is vital.”’.³⁷

A randomized trial to compare the efficacy, safety… [Int J Clin Pharmacol Ther. 2001] – PubMed res

3 http://en.wikipedia.org/wiki/Caduceus_as_a_symbol_of_medicine

4. http://en.wikipedia.org/wiki/Syringe

5. http://en.wikipedia.org/wiki/User:Pinaki_ghosh

6 http://power-publishers.com/

7. http://en.wikipedia.org/wiki/Novel

8. http://en.wikipedia.org/wiki/Drug_abuse

9. http://en.wikipedia.org/wiki/Comics

10. http://en.wikipedia.org/wiki/India

11. http://en.wikipedia.org/wiki/Pharmaceutical_drug

12 http://en.wikipedia.org/wiki/Antibiotics

13 http://en.wikipedia.org/wiki/Physician

14 http://joincome.wetpaint.com/

For epathy

15 http://en.wikipedia.org/wiki/Farmers’_suicides_in_India

http://articles.timesofindia.indiatimes.com/keyword/yavatmal-district/recent/3

[Check news from ‘06]

http://www.business-standard.com/india/news/farmer-suicides-persist-in-yavatmal-district/81248/on

http://articles.timesofindia.indiatimes.com/2009-09-17/pune/28084649_1_kishore-tiwari-yavatmal-district-vidarbha

http://www.edelgive.org/documents/Farmer_suicideReport.pdf

16 http://www.medhelp.org/posts/Fertility/Self-injecting-and-air-bubbles/show/321613

http://en.wikipedia.org/wiki/Air_embolism

17http://en.wikipedia.org/wiki/Medical_humanities

18A meta-analysis of controlled clinical trials comp… [Indian Heart J. 2001 Mar-Apr] – PubMed result

19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562216/pdf/canmedaj00525-0096.pdf

http://emedicine.medscape.com/article/761367-overview#a0104

http://allnurses.com/infusion-nursing-intravenous/air-embolism-iv-96687.html

http://en.wikipedia.org/wiki/Air_embolism

When it is written 2ml/kg, you have to multiply weight of the person with 2. For ex. For a man with 50 kg wt, 100ml is dangerous level of exposure. Severity depends on factors like whether foramen ovale is patent or not, whether air was rapidly introduced, proximity of air to right side of heart, etc. References are present in pathology books also.

20 http://en.wikipedia.org/wiki/Protagonist

21 http://en.wikipedia.org/wiki/Antagonist

22 http://en.wikipedia.org/wiki/Cardiologist

23 http://en.wikipedia.org/wiki/Sedative

24http://en.wikipedia.org/wiki/Vial

25 http://en.wikipedia.org/wiki/Patient

26 http://en.wikipedia.org/wiki/Medical_prescription

27 http://en.wikipedia.org/wiki/Hospital

28 http://en.wikipedia.org/wiki/Midazolam

29 http://en.wikipedia.org/wiki/Intravenous

30 http://en.wikipedia.org/wiki/Icon

31 http://en.wikipedia.org/wiki/Ailments