The ambulance left the hospital. A part of me went with it.
It was sometime after midnight.
I don't remember the exact time.
In an ICU, after enough hours, time stops being measured by the clock.
It is measured by blood pressures.
Oxygen saturations.
Urine output.
Vasopressor doses.
And sometimes—
by how long a human body can continue fighting.
The patient had been deteriorating for several hours.
We had done what we could.
Oxygen support had been escalated.
Fluids had been carefully considered.
Vasopressors were running.
Antibiotics and other indicated treatment had been given.
The monitors continued their relentless alarms.
Every few minutes, I found myself looking at the same numbers.
Hoping they would change.
They did.
But mostly in the wrong direction.
I stood at the bedside and went through the case again in my mind.
Was there something I had missed?
Another reversible cause?
Another intervention?
Another drug?
Another way of buying time?
That is what physicians often do when a patient deteriorates.
We don't immediately accept defeat.
We search.
Again.
And again.
But eventually I had to confront the problem that no prescription could solve.
The patient needed a level of care that we could not provide there.
A superspeciality opinion.
Possibly an advanced intervention.
Facilities available only at a higher centre.
And the higher centre was hours away.
---
The Decision
The family was waiting outside.
I called them in.
They had been watching people enter and leave the ICU all night.
Every time the door opened, they looked towards it.
That look is difficult to describe.
Fear mixed with expectation.
They wanted me to say something reassuring.
Instead, I had to explain uncertainty.
“His condition is very critical.”
They listened silently.
“We are continuing treatment, but he may require facilities that are not available here. A higher centre would have more advanced support.”
For a moment, nobody spoke.
Then one of them asked the obvious question.
“Then we should take him?”
I hesitated.
Not because I didn't know the indication for referral.
I hesitated because I knew the other side of the decision.
The patient was unstable.
Transporting him was not like transferring an ordinary patient from one hospital to another.
His blood pressure was being supported.
His oxygen requirement was high.
His condition could deteriorate at any moment.
There would be no ICU on the highway.
So I told them the other truth too.
“The journey itself is risky.”
Their faces changed.
“If we take him, will he reach?”
There are questions for which a doctor desperately wishes there were better answers.
“I cannot guarantee that.”
Then came the next question.
“If we don't take him?”
I looked towards the ICU.
“We will continue everything possible here. But we don't have some of the facilities that he may need.”
And there it was.
The entire dilemma reduced to two choices.
Stay in a hospital that may not have everything he needs.
Or—
leave the hospital in search of those facilities when he may be too sick to survive the journey.
---
Then the Patient Asked Me
Later, I went back inside.
He was exhausted.
Breathing was difficult.
His face carried the fatigue of someone who had been fighting his own body for hours.
But he was still conscious.
He looked at me.
“Doctor…”
I moved closer.
His voice was weak.
“Will I survive?”
I have answered thousands of questions as a physician.
Some require knowledge.
Some require experience.
Some require only a few seconds.
But this one never becomes easy.
Because I knew how sick he was.
I knew what the numbers meant.
I knew what could happen in the next hour.
And yet I also knew that the person lying before me was listening to every word I was about to say.
A physician's words carry enormous weight at such moments.
False reassurance would be dishonest.
But hopelessness can also be cruel.
I pulled a chair closer to the bed.
I held his hand.
“Your condition is serious.”
He continued looking at me.
“But we are still treating you. We haven't stopped. You keep fighting with us.”
He nodded faintly.
Then he closed his eyes.
I don't know what those words meant to him.
But I know what they meant to me.
They meant:
I cannot promise that you will survive.
But I can promise that I will not abandon you because you may not.
---
The Referral
After discussion with the family and arrangements for transfer, the decision was made.
We would refer him.
But before the ambulance could leave, there was another battle.
Stabilise him enough for a journey that his body might not tolerate.
Check the oxygen.
Secure the lines.
Ensure the necessary medications and support.
Explain the risks again.
Prepare the referral documents.
Speak to the family.
Reassess.
Then reassess once more.
Finally, the stretcher began moving.
Through the ICU doors.
Down the corridor.
Towards the ambulance.
The family followed.
I walked with them for a while.
Before he was taken inside, I looked at him one last time.
For us, it was a referral.
For him, it was a journey between two possibilities.
One hospital behind him that had reached its limitations.
Another hospital ahead that might have what he needed.
And between the two—
a road.
---
The ambulance doors closed.
The siren started.
I watched it leave the hospital gate.
Then I returned to the ICU.
There were other patients waiting.
Other monitors alarming.
Other decisions to make.
Medicine does not stop because one patient has left.
But somewhere in the back of my mind, I was still inside that ambulance.
Is the blood pressure holding?
Is the oxygen saturation stable?
How far have they reached?
Will they make it?
---
The Call
Some time later, my phone rang.
It was one of the relatives.
I knew before answering that calls at such hours rarely carry good news.
“Doctor…”
There was crying in the background.
“He became very serious on the way.”
A pause.
Then the words came.
He couldn't reach the hospital.
For a few seconds, I said nothing.
The ICU around me continued exactly as before.
The monitors kept beeping.
The staff continued working.
Another patient's infusion pump alarmed.
But inside me, everything became quiet.
The patient we had referred in the hope of giving him a better chance had died before reaching the place where that chance existed.
---
The Question That Remained
For the rest of the night, one thought kept returning.
Did I make the right decision?
It is a dangerous question because it has no end.
What if I had kept him here?
What if I had referred him earlier?
What if we had waited another hour?
What if he had reached the higher centre?
What if the same outcome would have occurred regardless?
There was no way to know.
That is one of the cruelest parts of medicine.
We know what happened.
We rarely get to know what would have happened.
And so physicians sometimes carry invisible alternate histories of their patients.
The patient who might have survived if transferred.
The patient who might have survived if not transferred.
The intervention that might have worked.
The extra hour that might have mattered.
The decision that might have changed everything.
We carry these possibilities even when nobody else knows they exist.
---
What Medical Books Don't Tell Us
Medical textbooks teach us when to refer.
Guidelines tell us what level of care a patient requires.
Algorithms tell us what to do next.
All of that is essential.
But there is a small distance between an algorithm and reality.
Sometimes that distance is 200 kilometres of road.
A guideline may say:
Refer to a higher centre.
It does not travel inside the ambulance.
It does not watch the blood pressure fall halfway through the journey.
It does not hear the family asking whether they should turn back.
It does not stand at the hospital gate wondering whether the patient will ever reach the destination.
The physician does.
That is why practising medicine in a resource-limited setting teaches a different kind of medicine.
Not inferior medicine.
Not careless medicine.
But medicine constantly negotiating with reality.
You learn to ask not only:
“What does this patient ideally need?”
but also:
“What can I safely provide here?”
“What can the higher centre offer?”
“Can this patient survive the transfer?”
“Can I stabilise the patient enough to give that journey a reasonable chance?”
And sometimes—
“Which of two dangerous choices gives this patient the better possibility of survival?”
There may be no perfect answer.
---
The Hardest Part
People sometimes imagine that the hardest part of being a doctor is seeing death.
It isn't always.
Sometimes the hardest part is seeing death approaching while still having decisions to make.
Because as long as there is a decision, there is responsibility.
And responsibility creates doubt.
A patient may die despite appropriate treatment.
A patient may die despite timely referral.
A patient may die during transfer.
And sometimes a patient may survive against every expectation.
Medicine gives us probabilities.
Patients give us outcomes.
The two do not always agree.
---
That night taught me something I have never forgotten.
Hope is not the same as a promise.
When a critically ill patient asks,
“Doctor, will I survive?”
perhaps my responsibility is not to manufacture certainty.
It is to give truthful hope.
To say:
“You are very sick. But we are here. We are treating you. And we will keep trying.”
Because sometimes that is the most honest hope a physician can offer.
---
Behind the White Coat
The next morning, people saw me walking out of the hospital.
White coat.
Stethoscope.
Files in hand.
Another duty completed.
From outside, nothing looked different.
But physicians sometimes leave hospitals carrying patients who are no longer inside them.
A conversation.
A face.
A final question.
An ambulance disappearing through a gate.
And the thought—
Could I have done something differently?
Perhaps that is part of the profession that remains invisible.
Behind every confident clinical decision may be a physician who has considered several frightening possibilities before choosing one.
Behind every referral letter may be a doctor hoping the patient survives the road.
Behind every statement—
“We are doing everything possible”
—is sometimes a physician painfully aware that everything possible is not always everything that exists.
And behind the white coat is still a human being.
A human being who sometimes has to choose between two uncertain paths.
A human being who knows that either path may end badly.
A human being who nevertheless has to choose.
Because medicine does not always give us the privilege of certainty.
Sometimes it gives us a critically ill patient, limited resources, a distant higher centre and a few minutes to decide.
And in those moments, I have learned that my duty is not to guarantee life.
My duty is to protect every reasonable possibility of it.
To recognise the limits of my hospital without surrendering to them.
To refer when referral offers a meaningful chance.
To stabilise before sending whenever possible.
To explain the risks honestly.
To preserve hope without giving false assurance.
And above all—
never to let a poor prognosis become an excuse to stop caring.
Because there will always be patients I can save.
There will be patients I cannot.
And there may always be a few whose ambulances I will remember long after they have disappeared beyond the hospital gate.
Those are the patients who remind me that sometimes the heaviest thing a physician carries is not the stethoscope around the neck.
It is the uncertainty of whether the decision made in the hope of saving a life was the road that gave that life its best possible chance.
— Dr. Sachin Swargiary
Behind the White Coat