Friday, 29 June 2012

Diary of a Young Doctor(part 3)

(published in The Friday Times on 29th June, 2012)

Diary of a Young Doctor III

"Please guide us, doctor. We have come back because the local dispenser [quack] refused to administer the injection you wrote for our son, saying it is too 'heavy'." 

I was busy making the 'discharge form' of a patient when that couple came towards me and said those lines. Their teenage son had been discharged yesterday upon their request, and I had prescribed an injection that he needed every day for the next week. The couple said they would get their son the shot through a dispenser in their locality. And they were back the very next day.
A doctor can, just by clicking on the computer screen, get free medicines for needy patients

This is not a unique situation. Apart from managing patients feigning abdominal pain in the emergency ward and waking up during the "on call" nights after every hour to change a transfusion bag, this is what young doctors do in "routine". A routine day comprises duty of about 6 hours, from 8 in the morning to 2 in the afternoon. We start the day by checking patients on the beds allotted to us and by writing down the DPNs (Daytime Patient Notes). This is followed by a survey of our work and additional examination by our immediate seniors, the Medical Officers. After that, there is the ward round by any one of the designated consultants/specialists. During the round, the consultants listen to the medical history of patients from house officers or medical officers and look through the investigations carried out previously. Then, according to the situation of the patient, investigations or different drugs are advised which are added later to the charts by House Officers.

If the patient is newly admitted and can't buy medications on their own, there are two ways of getting them free medicine. There is a list of medications that are provided to our wards every day by the hospital. They include most of the commonly required drugs, and a doctor can, just by clicking on the computer screen, get free medicines for needy patients. Another way is through the Medical Superintendent (MS) of the hospital. For that, the patients' file has to be signed by the MS himself, which is not a hard thing to do. Then there is the problem of urgent investigations. For that, house officers have to counsel the attendants and sometimes have to get involved themselves to get those tasks done through the emergency department. At times, the bureaucracy of it all can get in the way and frustrate patients.
I have seen patients who think they are not being treated fairly threaten the doctors by mentioning political figures or members of the bureaucracy

As in the rest of Pakistan, a patient is likely to get sufficient attention (which mostly means more than normal) if they know someone in the hospital hierarchy. This doesn't mean that doctors don't care for their patients; it's just that we find it difficult to divert our energies where they are not required.

This 'protocol' business can turn ugly. Many a times I have seen patients who think they are not being treated fairly threaten the doctors by mentioning political figures or members of the bureaucracy. It happens particularly frequently in the hospital where I work because we have to deal with all kinds of government employees and their kith and kin. According to one of my seniors, even if the gardener of CM house brings a patient to the hospital, he expects to get 'protocol' equal to that of the CM himself.

Hospitals are great places, not only for learning medicine but also for learning about the different shades of life. I would like to mention some of the most interesting cases I have seen in my brief clinical career.

The fiancee with the headache before her FA exams brought to the emergency by her very concerned fiance, the CA student who had not eaten anything for a month due to some kind of love affair; the 65 year-old woman patient who insisted on smoking despite the disease in her lungs; the helpless relatives of a 70 year-old woman who had to get dialysis but couldn't find the hospital where it was urgently available; the 50 year-old woman with tuberculosis of the meninges (brain coverings) and an untiringly colorful vocabulary; the madrasa student who sat for his Dars e Nizami exam while he was admitted in the hospital; the women loudly reciting Quranic verses around a very sick patient and freaking out the doctors; a 15 year-old boy spending most of his time around his ailing mother in the ward and running around taking her samples for laboratories; the young patients (mostly girls) with acid/bleach intake for suicide purposes and the attitude of their families towards them; and all those patients who are never satisfied when they are prescribed pills and demand injections and drip infusions just to feel medical; and all the drug mules who are accompanied by police or custom officials and deny any wrongdoing until the last minute.

There are also issues among various departments in the hospital that cause unnecessary delays in diagnosis and treatment of patients. The Radiology and Pathology departments provide services to all the rest of the Hospital, and are indispensable in the management of patients. If the same tests are to be done from private labs, the cost is not affordable for most of our patients, who belong to the lowest strata of the society economically.

I would also like to mention that there are almost no holidays for young doctors during their house jobs. In the department where I work, we only get 2 holidays in a month, both Sundays. Apart from that, we only get one emergency leave per month.


Friday, 15 June 2012

Diary of a young doctor (part 2)

(published in The Friday Times, on 15th June, 2012)

here was a frantic knock on the door of the doctors' room. A half-asleep lady came in abruptly. It was 2 o'clock in the morning and there was absolute silence in the rest of the ward. The lady gasped and said, "Dr Sahib, the condition of my patient is serious, can you please come and check her?" I had no option but to get up from the couch I was lying on, get my stethoscope and accompany her to the bed of that patient. As it turned out, the lady was a patient of liver failure and was having pain in the abdomen. After a brief checkup, I wrote down a simple ant-acid and asked the patient to take some water. Problem Solved. Sleep be damned.

The above-mentioned scenario is one of the many that we have to endure during our 28-30 hour long ward duties, also known as "long calls". After a regular day at work, the whole ward becomes the responsibility of 4-5 doctors who are said to be "on call" while the rest of the doctors go home. This duty has to be done once a week and at a weekend once a month. The regular tasks that we are required to perform during our calls include noting down blood sugar levels of diabetic patients, monitoring blood pressures of any serious patients, doing a routine checkup of patients in the ward, dealing with occasional complaints (like the one mentioned above) and lastly, to oversee casualties that occur on our watch. We are required to be present in the ward at all times during duty hours, and it basically means little rest and little to no sleep. After every 5-10 minutes, there are knocks on the doctors' room and one attendant after another barges in to get the required "attention" for their patients. In many cases, the condition of the patient is "irretrievable" and it is difficult for both the doctor and the attendant to see the patient suffer. Most of the patients admitted in medicine wards are suffering from either chronic liver disease (due to very high prevalence of hepatitis in our population), tuberculosis in its various forms, stroke (known as 'brain hemorrhage' in popular culture), kidney failure, meningitis (infection of the coverings of brain), chronic pulmonary disease (due to long-term smoking) and fever due to infections. Patients are checked twice daily, once in the morning and once in the evening.In a country with so many health-related issues, negligible amounts of money are being spent on patient care in public hospitals. A lot of patients can be saved by provision of simple ventilators but the number of ventilators across hospitals in Lahore is no more than 100-150! Similarly, dialysis units and liver transplant facilities, which are considered routine in developed countries, are not easily available in most tertiary care hospitals in our country. The human aspect of being a doctor can be seen during ward duties, as doctors give their best efforts and energies to save the patient without having any relation with the patient. In many cases, young doctors work out of their comfort zones to treat the patient as well as is humanly possible.
Young doctors are the wheels upon which the health care system is working
The culture of attendants in our country is not only cumbersome but also problematic at times. Due to socio-cultural beliefs, more people are willing to stay with the patient than is necessary. The problem arises when doctors are inconvenienced by attendants craving attention, leading to neglect of other patients. Even when forced to leave the ward during rounds, the attendants are back as soon as the restriction is over. Last year, a team of doctors were visiting from the United Kingdom for a project and they were surprised to see so many attendants in our wards. They recounted that in the UK, attendants are allowed to visit the patients only during scheduled hours and even at those times, so many attendants were not allowed to visit the ward, ultimately avoiding the mess that we have to face. At this juncture, I would also like to point out that the running of emergencies and the wards is primarily done by the young doctors and they are the wheels upon which the healthcare system is working, despite all glitches. It is an unfortunate reality that most doctors working in public sector hospitals are not even paid for their jobs, making their work more worthwhile than it already is. As I wrote earlier, there is acute shortage of bed space in public sector hospitals. Last year, during the dengue outbreak, when the Chief Minister visited many hospitals including the one I work at, he was appalled to note that two and in certain cases three patients were present on one bed. Based on his instructions, patients were adjusted but it was a short-term measure and the situation remains the same. I personally have had to discharge patients at times because of acute shortage of space. I felt extremely bad doing that but the patients themselves wanted to go home and be comfortable. The toughest aspect of ward duty I found was the time of casualties. The usual scenario goes like this. Doctors are mostly aware of the patients who are having a really bad time and they try to counsel the relatives beforehand. When a distraught attendant comes running in, calling for attention, the concerned doctor rushes to assess the patient. When the patient is critical, the doctor calls his batch mates for help and combined efforts are done to resuscitate the patient. If the patient can't be revived, the protocols are followed and the attendants are informed about their patient's demise. The response of the attendants to the news depends on various factors including the age of the patient, disease of the patient and the quality of counseling done previously. In case of young patients, the reaction of the relatives is quite severe and I have seen my colleague's collars ripped off by an angry relative. Due to their inability to cope with grief, many attendants blame the doctors for the casualty of their patient, without acknowledging the work done by the same doctors when that patient was alive.
At the end of the day, it is not a fair world and a doctor can do only as much.   

Wednesday, 6 June 2012

Goodbye,Dr House

(published by Express Tribune Blogs on 6th June, 2012)

As the saying “all good things come to an end” 
goes, “House M.D.”, the brilliantly written show, ended last week. There have been numerous television dramas over the years based on doctors and hospitals including “General Hospital” from the 60s to “Scrubs” and “Grey’s Anatomy” during the 2000s. “House M.D.” embarked on a journey to create its own presence and niche when it first aired in 2004.
It is based on an ingenious but misanthropic doctor who is willing to cross all boundaries to solve a case. His actions are seen to be driven by his passion for medical puzzles and mysteries, instead of a general feeling of care and well-being for his patients.
The character is loosely based on Sherlock Holmes, the fictional character created by a Scottish physician and writer, Sir Arthur Conan Doyle. Dr House is a graduate of Johns Hopkins school of medicine and has served fellowships in nephrology and infectious diseases. In the series, Gregory House heads the Diagnostics Department at Princeton Plainsboro Hospital (PPTH), in New Jersey. The department takes only one patient at a time with barely any criteria for selection. Usually patients with atypical symptoms are dealt by the Diagnostic Department. Both the department and the hospital are, however, fictional.
In the first three seasons, his team includes Eric Foreman, a neurologist, Dr Chase, a cardiologist  (later head of surgery and then the department of diagnostics) and Dr Allison Cameron, an immunologist. Other important characters include Dr Lisa Cuddy, the administrator of PPTH and Dr James Wilson, an oncologist and the only friend of Dr House. House abides by one golden rule about patients and life in general – “everybody lies”. That is the reason he seldom talks to his patients or even believes in what they tell his team about their medical history.
Hugh Laurie, a British actor, plays the character of Gregory House and his acting attracted nothing but praises from the general viewers and critics. Despite his British accent, he effortlessly adopted the American accent throughout the show.The show was popular not only amongst people with medical backgrounds but also for aficianados of acting and drama. The character House is famous for his witticisms and there is a whole website dedicated to “House-isms”. I would like to mention some of the quotes here for all of us to enjoy and reminisce the intelligent humour we all will miss the most.
House: “Me and humanity, we got together too young.”
Patient: “How do doctors get this idea that you are better than everyone else?”
House: “Probably because of all that ‘pulling people back from the brink of death’, but its just a guess.”
House: “Treating for wrong diagnoses can result in side effects, like death.”
Chase: “The dream doesn’t mean anything. Can we start acting like it doesn’t mean anything?”
House: “Sure. We can also act like walls don’t mean anything. But then we’d hurt our noses.”
House: “Evolution does not work that way. You can’t talk legs onto a fish. If we’re going to go extinct, we’re going to do it drinking Scotch and driving muscle cars.”

House M.D. means more to me than a simple drama for the purpose of  entertainment, which it definitely provided its viewers with. I started watching it when I was in medical school and even now, when I am undergoing my clinical training, I still watch it. It evokes so many memories that I feel difficult to let it go, like many of its fans.
House M.D. will live on, even after it goes off air. It will and may have already inspired countless people towards the medical profession. It showcased the much-neglected human side of doctors emphasising on their human errors. With teary eyes, I bid farewell to one of my favourite television shows, House M.D.
My Tuesdays will be emptier without another episode of the show and if I ever develop any atypical disease, I would want someone like House M.D. to treat me. He may dismantle my hopes for living but at least he would not let me die due to a lack of effort.

Friday, 1 June 2012

Diary of a young doctor(part 1)

(published in The Friday Times on 1st June, 2012)
felt as if I could not move my legs. It was as if my body was disobeying my mind.It was 4:45 a.m. and my alarm bell was piercing my eardrum. I did the only thing I could do at that time: I pushed the snooze button. I knew I had to get up in a few minutes and by then my legs probably would have enough energy to crawl out of bed and move. It was a Saturday morning and I had to be in the 'Accidents and Emergency Department' for my 12-hour duty from 6 a.m. to 6 p.m. I had returned the previous day after doing a 28-hour ward duty which included very little sleep and quite a bit of leg work. The reason my body was temporarily refusing to obey my mind was my tiredness and lack of energy. In the end, I made it to the emergency department and performed my duties as a House Physician for 12 hours straight. This is how the life of a young doctor unravels.
A lot of patients visit the emergency ward because they want "urgent" treatment of things that can be easily dealt with on a regular schedule
I am a medical graduate undergoing my first year of medical training known commonly as House Job. Being on the junior-most rung in the ladder of the public health care system, we are the first point of contact for the people coming to public-sector hospitals. We have to perform emergency duty once a week and twice every other week. In the emergency department, we treat the patients who require urgent consultation with a physician. The patients come in, we examine the patient and write medications for them accordingly, their attendants get the free medications from the medical store located inside the department and those drugs are then administered to the patients by the nursing staff. This chain is the usual protocol followed in most public sector hospitals. In some cases, some drugs are not available in the medical store inside the department so the attendants are asked to get them from any nearby store.In the hospital where I work, we have the Hospital Management Information System through which we enter medications for patients using laptops and they can get their medication from the medical store without any hassle. On a regular basis, we treat patients suffering from gastroenteritis (caused mostly by unhygienic food and water consumption), fever and body pain, and patients who are already on medication for chronic conditions like diabetes, kidney failure, liver disease or heart disease. Patients are charged only for the minimal admission fee; laboratory tests and radiological investigations, including X-rays, ultrasound and CT-scans, are done without any charges.
I return home with an aching back, an empty stomach and pain in the balls of my feet
Emergency Duty is mostly spent by us while moving from bed to bed and not being able to sit for more than five minutes. There are very few seats available in the emergency department and most of the work is done without much respite. During the duty hours, more time is spent by us counseling the patients and their attendants than actually treating people. Everyone wants to get our attention first and it can become hectic very fast, with beds filling up to twice their capacity and still more patients streaming in. Things can get heated as well and incidents of fights between the doctors and patients have been noticed in the last few years. There are no security guards in the emergency rooms, leaving the duty of self-defense to the doctors themselves.Incidents of bullying by attendants led to the formation of the Young Doctors Association 5 years ago.The facilities that I have described above are at par with almost any private hospital in the city. But the only people who tend to visit public sector hospitals are of the lower-middle class or the lower classes. One reason for this is that there is a shortage of both space and personnel in public sector hospitals. We cannot refuse treatment to any patient and this puts a strain on our already scarce resources. A lot of patients visit the emergency ward because they want "urgent" treatment of things that can be easily dealt with on a regular schedule. I have personally seen patients of sinusitis, occasional headaches, acid peptic disease and increased blood pressure in the emergency ward while all of them are theoretically out-door department cases.In the emergency room, a house officer examines patients, takes blood samples, passes nasogastric tubes or folley's catheters, checks blood sugar levels and blood pressure and has to write prescriptions on discharge of the patients. These few tasks are repeated from the start of the duty till the duty finishes after 12 hours. There are times when the inflow of patients is very high and it becomes extremely difficult to shuttle between patients based on the severity of their symptoms; and there are times when most patients are stable and the doctor can catch his or her breath for a while.Apart from fulfilling our duty, we also receive many prayers and good wishes from patients who are successfully managed. The road is not full of roses, though, and patients complain if the treatment is not working. The toughest aspect of the job is to face the incidents of mortality in the emergency. In most of the cases I have seen, attendants raise a hue and cry at the death of their loved one, and that frightens the rest of the patients. In those moments of grief, all the doctor can do is to inform the attendants and get signatures from them on the death certificate.As for me: at the end of the 12-hour duty, I return home with an aching back, an empty stomach and pain in the balls of my feet. I try not to walk much after I reach home and after a few hours of rest and some dinner, go to sleep, ready for another day at work.