I have long been an advocate of a no refusal, admit all patients policy for physicians . Any physician is bound by his Hippocratic oath and the law to treat any patient (within the bounds of his skill and expertise) whatever the circumstances of that patient will be. The physician also has the social responsibility of reporting any patient (to proper authorities) that may pose danger to any other person or to the society for which the patient belongs.
Lately however, I’ve noticed a few non-compliant patients pushing limits of our patience and resources. My case in point.
A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet slug is palpable on the postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and scheduled the patient for an emergency debridement and external fixation of the fracture. Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days after surgery. The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found. My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.
If he ever goes back to any hospital, and if you are the physician, what would you do?
The dilemma is much more difficult in government hospitals. In the Philippines, government hospitals are funded by people’s taxes. Funding that are at less than optimal and is finite. Government physicians sometimes sees patients, that for some reason,are rarely compliant. Most often these patient’s’ non compliance results to complications and prolonged treatment. Prolonged treatment siphons physician and hospital resources that could have been allocated to other patients. This is where the decision making abilities of a physician enters and is very crucial. It can actually make or break his career because litigation and malpractice suits isn’t easy to come by.
My take on this? I’d still treat the patient according to what his medical problem requires and to what treatment the patients consents to. But I’m going to document it very carefully and protect myself with detailed consents and waivers. I will also get the opinions of appropriate legal or social services department. Sometimes, its more with communicating with the patient and convincing them of their most beneficial treatment option. This is not easy. But aren’t we surgeons and doctors now if our job is easy?
I may sound like crap but again, the simple fact remains the same. We are the physicians, the very persons privileged to touch and care for sick people. When we treat patients, we (and the hospital) enter a ‘contract” with that patient. Contract that to an extent, requires both the doctor and the patient to work for the wellness of the patient, for so long as that treatment is not detrimental to others. It all boils down to both parties being aware of their responsibilities in this contract. If one violates this contract, that ceases the existence of the contract and therefore, ceases the doctor- patient relationship.
If you are a physician in this situation, what would you do? If, you are a patient, what do you think should the physician do?
Once in a while, in our busy and chaotic medical life, a few patients would come by and jerk you off your comfort zone for empathy and go bonkers on the absurdities of life. They come into your clinic like the usual patients complaining of this or that disease. The moment you ask these patients about their history however, you pause at one point in awe and be moved for a while. Something hit you and had hit you hard. You are, in medical numbspeak, “infected” with their moving story.
One of my few personal favorites is the story of Mang Pedring. Mang Pedring, is a fifty something bread winner of his family. The father of four and a laborer, he frequents and works part time inside these gambling site to earn his living. He barks (as kristo) in a cockfight, a tayador in a tumbo (I wont bother expounding on this because I really have a vague idea what this coin gambling is) and a meron in a card game called Pusoy or tsikitsa. He broke his left arm after falling off a motorcycle. He was on his way to the cockpit- the gallery for cockfighting.
A cockfighting match barker or kristo doing his stunt in the game to earn his living (Photo credits to the original owner)
It was almost a month after his injury when he sought consult at my clinic. Prior to this, Mang Pedring went to a number of bonesetters, a doctor, and was actually admitted in one hospital for 5 days. His last closed reduction and casting didn’t went well for some unknown reason (I learned later, that he took off his mold because it felt so tight for him, without consulting his previous doc). What’s worse is, he drained his funds going through all these unsuccessful attempts at “fixing” his broken arm.
Funds, which he revealed, was a pool of money earned from gambling- from the throw in of his fellow gamblers when they learned of his predicament, and (the most disheartening was) what he earned as a cockpit kristo or barker while his right arm is strapped in a sling and a cast. That helpless ironic sight, as I imagined from his story, made me twitch in empathy. I cannot imagine raising my broke arm in an attempt to earn my living, much more do it in a gambling site. He came begging me to fix his arm so he can go back to his ‘work” and earn for his family.
What I was trained of course, is not to give weight on his conflicting circumstances but focus more on his ailment, which is his broken arm. Orthopods were trained well to aim at a holistic treatment of a “broken” patient- to return the patient to his functioning, pre injury status. In Mang Pedring case, to his gambling “work”.
I owe it to Hippocrates and to mankind to do just that and leave the morality of his gambling work to the society’s judgment. In fact, I never pass on judgment unto Mang Pedring. I simply wanted to bring him back to his pre injury level. Whether his work qualifies (or not) as a job for many of us, that is not my concern and is not what struck me in his story. It is his struggle to earn a living while still on the mercy of a cast over his left arm. The ghastly scene is further brutalized by having to work as a barker in a cockfight. What suddenly flashed in my mind? A wounded gladiator.
Funds depleted, and totally frustrated at his broken arm, I reapplied his cast ( as a temporary “fixation”) while we where looking for funds for his operative treatment. I said I could help finding a sponsor for his metal implant and negotiate for a “free surgeon”. He only has to look for his medicines needed during the operation. Right there, I saw Mang Pedring’s eyes beaming with happiness. He cried in front of me. Cries, which really whacked me out of my objective senses for a minute. I saw his desperation. I saw his hope. Now his desperation is mine too. His hope, lies in what I could do to ease out his predicament. I have to fix his broken arm. Soon. Fast.
Then what he said (in hiligaynon) before leaving struck me the most:
“I gotta get back to the cockpit and the tumbuan doc and ask again for a “throw- in” for my surgery. I know people there would help me”
I scratched my head in disbelief. Mang Pedring was and even in dire needs, look up to his gambling and fellow gamblers for help. Whatever our society has passed judgment as morally wrong wouldn’t matter to this guy for as long as it saves his limb and and put food in the table for his family. For once, I thought Jesus, the kristo, was disguised as a gambler. Mang Pedring is and will probably be a gambler. But his aspirations and dreams were similar (or parallel) to the non gambling patients I’ve treated. He wanted to return to his job and feed his family. Whether his method or job is morally wrong to some of us that is not my hemisphere of expertise. I simply wanted to return him to his pre injury functioning level. Period.
After 2 more casting sessions, Mang Pedring didn’t come back to my clinic anymore. While in the process of “pooling” funds for his surgery, he felt his armed healed already and removed his cast. Of course I wanted to confirm that with an x-ray. I also wanted to see if the money he pooled is really safe in his piggy bank and not to the gambling aficionados. I didn’t get that chance. One gambling insider later told me Mang Pedring is back in the cockpit again, without his cast and seem to have a functioning arm. I just smiled. Perhaps my work has ended successfully there.
Perhaps, I made a gamble on Mang Pedring.
(Photo credits goes to Islander in the City, here)
That is, if you believe what U.S. Preventive Services Task Force– a government-sponsored expert panel that evaluates preventive tests, is telling healthy adults in the US. This meant that of the countless battery of tests that are included in those “executive” work up, only eight, I repeat-only eight will “likely lead to a better health”. I’m not so sure about what where there basis for choosing this eight but I suspect clinical studies that validate it on a public health scale should be one of them.
Nonetheless, and pending reactions from our public health authorities here in our country here are the “test” and their range of acceptable values as published in Forbes Magazine.
I am not sure how our colleagues in the medical profession will react to this and so our public health officials. I am more interested in its implications towards my well adult patients and the health care cost reduction it will offer. Surely that will go a long way in them digging hard into their pockets.
A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet slug is palpable on the postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and scheduled the patient for an emergency debridement and external fixation of the fracture. Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days after surgery. The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found. My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.
