Prudence and Madness

One part of my work I hate is being caught between clashing rocks: a private hospital wary about admitting indigent patients and cautioning their doctors from doing so, instructing them to direct these patients to government hospitals as much as possible, and patients and their relatives who’d stubbornly insist on being admitted/treated in an expensive, private hospital despite being warned about the estimated cost, being obviously with financial constraints.  Being put in the middle of this often ferocious haggling (since nobody would want to give in) just puts unnecessary stress on the doctor involved whose main job ought to be just the active management of the patient.  After all, he’s just the doctor and not the hospital administrator.

Such an occurrence again happened to my 24-hour duty last Sunday.

At around 9 PM, we, at the ER, heard some shouting outside the hospital lobby doors.  Minutes after, the security guard saw four seemingly drunk males walking the length of the driveway leading up to the emergency room.  When the strangers got close to the ER doors, we saw they were all apparently victims of stabbing, clutching their abdomens.  Two were almost collapsing on one another and one half-carried, half-dragged his companion.  We quickly pulled out the stretchers.

Tom (not his real name), the one half-carried and half-dragged, was dead on arrival.  His guts were spilling out from the 3- to 4-inch wide stab wound in his abdomen, just above the umbilicus.  CPR was attempted but soon he was pronounced dead.

Carl (not his real name) also suffered from a similar stab wound and his guts were also hanging out of his abdomen, although less worse than that of Tom.  He was still breathing, conscious, and coherent.

Dan (not his real name) was stabbed in the left lower side of the torso and the wound was actively bleeding.  But, otherwise, he is still conscious and ambulatory.  He was even texting using his cellphone while lying on the stretcher.

Rey (not his real name) was the luckiest of the group and suffered only superficial stab wounds on the upper abdomen, almost near the diaphragm and on the left side of the chest near the axilla.

Of the three left alive, two needed major operations:  exploratory laparotomy (vertical incision on the midline of the abdomen to check if any of the internal organs were violated and to put back the eviscerated intestines if not necrotic) for Carl, and wound exploration for Dan (to check the source of the active bleeding).

Of the four, only Carl had relatives that were easily contacted.  Soon they came to the hospital.  Minutes after, the previous employers of the four arrived.

I advised them that the three patients needed to be admitted in the hospital and that Carl and Dan needed major operations.  Since initial management has been done, I told them that a decision has to be made quickly as to whether they’ll consent to admission and to have the operations done or they’ll risk transporting the patients to a government hospital where their expenses will be lesser.

So now comes the almost never-ending haggling.  The hospital wanted them to make a deposit of, at least, P10,000 within 24 hours because 2 patients will be having major operations and the money can be used to cover the initial treatments and the units of blood that will be used.  The relatives just couldn’t make up their minds.  It’s one thing I noticed here in the country.  Whenever a person gets ill and brought to the hospital, all the relatives, neighbors, and even acquaintances will go to the hospital as soon as they hear the news.  But nobody would even be, at least, of help to those who ought to make the decision whether to admit or to transfer hospital, a decision made by the immediate family.  And then they waste valuable time trying to contact more relatives, which in turn would also come to the hospital but offer no help, even with the decision-making.  Soon, almost the whole barangay is outside the ER where the patient is.  That’s what happened last Sunday.

After some discussion, the previous employer convinced the eldest brother to have the patient admitted, as well as the other two, who were also her previous employees.  She said she’d help with the expenses.  But then she went away, saying that she just has to go and look for money for deposit.  She never came back.

I contacted the surgeon and the anesthesiologist.  Soon the consultants came and Carl was wheeled into the operating room.  Rey was transferred to the ward while Dan has to be left in the emergency room because his wife can’t decide whether to transfer her husband to a government hospital or to just consent to have him operated right then and there.  And so, the same cycle of calling up relatives and relatives coming but not necessarily helping in terms of financial and decision-making was repeated.

I felt so bad that I just can’t do more about it.  I have told them to transfer, while the patient is still stable and there is time, if money is the problem, so that valuable time (and patient’s life) can be saved.  I told them that their patient is bleeding and that everything short of an operation has been done to keep him from bleeding heavily but still he bleeds.  I told them that maybe one of them could go look or call for a free ambulance, since they can’t pay for the hospital ambulance, from the barangay hall.  But still, nobody dared moved.  All were just staring at me or looking down or somewhere else.  It’s frustrating to see those blank stares, as if they understood nothing of what I’ve just told them.  Didn’t they realize that I’m trying to help them so that they could save their patient’s life and, at the same time, not have too much financial burden?

Then came another relative.  This one was more outspoken and assertive.  She’s the aunt of Dan.  She stormed in the ER with a barrage of questions, “Why didn’t you start operating on the patient?  Can’t you see it’s an emergency?  What, are you waiting for a deposit to be made?  Bah, but that’s illegal!  You’re supposed to treat patients regardless of their status!”, etcetera.  It seemed to be endless but I tried calming her by telling her that  initial management has been given but the hospital is holding me back from admitting Dan because the wife couldn’t come up with a decision whether to consent to procedure or to transfer.  She then, turned to the wife and reprimanded her for being slow to decide.  When I asked if she would be willing to guarantee that, at least, an initial deposit will be made within 24 hours, she quickly withdrew and said that she can’t given consent because she’s not the immediate family of the patient.

After 5 hours, finally, the wife signed the consent.  Dan was operated on and the bleeding was effectively controlled.  Both Carl and Dan were stable, postoperatively.

The relatives were, then, updated as to the status of their bill.  And, as expected, everybody complained that it had became too expensive for comfort.  They whined about why I admitted their patients when I obviously know that they don’t have the money to pay for it?

So now it becomes my fault?  Haven’t I warned them that they’re in a private hospital and that operations would be expensive?  I even quoted them how much they should expect they’d be spending for the hospital bill.

Then, they’d whine about how they’re emotional and couldn’t think straight, etcetera.  Couldn’t just the hospital give a discount , they said.  If they wanted one, they should talk to the hospital administration and not me.  I work for the hospital, I don’t own it.

I find it frustrating when relatives of the patient won’t accept responsibility for the choices they make.  They would ask for all sorts of rights, even if already excessive.  Now that they have the power of choice, they draw back, muttering all sorts of excuses like having right to be emotional because they’re just humans or they shouldn’t be deciding because they do not understand medicine.  But isn’t the reason why they ask us, doctors, to explain to them everything as best as we can so that they can make an informed decision?  They ask that they have the right to choose what to do with their patient, and yet they don’t want to accept the responsibility that comes with that choice.

This kind of mentality is worsened by the fact that we, Filipinos, do not have easy access to proper medical care.

But most patients and their relatives see private hospitals as ill-meaning and are draining them of money on purpose because they’re only concerned with money and not of service.  But what right have they to say that?  Didn’t they see that we attended to their patients even with no guarantee that we’ll be paid for it?  Did they expect us that we’ll simply render service, expecting nothing in return?  If everybody who goes to the hospital with a mentality like this, then nobody would put up a private hospital business anymore because it wouldn’t be profitable.  Is profit evil?  Of course not.  A business that is profitable is what fuels everybody’s lives because it provides jobs and services.  If there will be no private hospitals and everybody has to rely on government hospitals which the government couldn’t even properly finance because it is too focused on infrastructure and tourism when it should be focusing more on health and education of the citizens, then what will become of us?

Perhaps, this is one of the reasons why I wanted to leave this country so badly.  As a doctor, it is complete satisfaction if we’re able to render good service to our fellowmen using all the knowledge we have incurred in our study and in our practice because that’s what we swore to do.  But to be able not to render that service because we’re held back by hospital politics or financial constraints and still be blamed because of it?  It’s defeating.  It can disenchant anyone, even the most persistent and diligent ones.

I’ve never liked politics.  Not even politics in medicine.  Sigh.  I don’t know how much of this clashing and blaming I can still handle.   As soon as I could pack my bags and leave, I will.  But no money just yet.  Maybe in the near future.

For now, I just have to make myself patient with politics in medicine.

Filed under: Health, Lifelogs by Prudence