Monday, September 19, 2011

A doctor's pain

About 2 months ago, Mr. Kamal came to our emergency department. He was a young man of 23 and had been a regular consumer of alcohol for about 5 years. He came with acute severe pancreatitis, which as most doctors know can be a killer. He had not passed urine for 2 days at home and his abdomen was distended like a balloon. We admitted him and began the supportive management that is all we have for this condition. He seemed to be improving for the first 2 weeks with his renal function improving and his distension gradually coming down. Then he began to worsen and we found on a CT scan that he had the dreaded complication of pancreatitis - pancreatic necrosis. He was taken to the operation theatre and the necrotic tissue was removed along with the placement of drains in the pancreatic bed to remove whatever further necrosis occurred. And now, 2 months down the line, Kamal has nearly reached the end of the road. His organs which were holding up till now are slowly shutting down. It will take a miracle for him to live for more than 2 or 3 days.

My thoughts have returned to Kamal and his family many times today. It is terrible to see a man in the prime of his life deteriorate from a healthy 90 odd kilos to mere skin and bone in a matter of weeks. To watch helplessly as a disease that is impervious to all the medicines that we can throw at it, ravage his body to the point of death. But I have seen this many times. And what makes it all the more difficult to swallow is what it does to the family. Kamal's older cousin is the one taking care of him. He has sold all his land and all the gold of the family to come up with the huge amount of money that it has taken to keep Kamal alive all this time. The month and a half in the ICU, the hugely expensive medicines and the long term ventilation have often come up to more than 30-40,000 Rupees every day. All the times I have talked to the family, they have been very clear that they would go all out - whatever the result. And now that it looks as if the end is near, I feel terrible every time I meet them. I no longer have any hope to share with them.

The other day, Kamal's cousin was in the room with him describing to the doctors the struggles the family was going through. Kamal can no longer speak as there is a tube in his trachea helping him to breathe and as the cousin told of all they had sold to keep the money flowing in, we forgot for a moment that Kamal could hear him. When we looked at him a few minutes later, there were tears streaming down his face. There were tears in our eyes too.

The tragedy of the situation is two-fold. Kamal's deterioration and impending death is one thing. But what makes it so much worse is the devastation his illness has had on his family. They have sold their land and gold, taken huge loans at astronomical interest rates and will take many years to recover from this blow. It is a story that medical professionals throughout the world (except in the very few welfare states) are familiar with. And though it happens many times, it never makes the pain easier to bear. Medical care should be life-giving and not life-spoiling. The Hippocratic principle - first do no harm, should apply even to the family - who are often the worst harmed by any illness. The inhumanity of our medical costs, driven by greedy medical professionals and unscrupulous corporations is something that has often troubled me. And every time I see someone like Kamal, I am reminded again of the painful irony we face every day - where saving a life often means despoiling a family.


  1. A poignant tale. But the question remains: if people don't pay for their own treatment, who does? For the money has to come from somewhere.

    And if taxpayers are made to pay for it, then is it fair to someone who maintains a healthy lifestyle to be burdened by the care of someone who chooses a not-so-healthy lifestyle?

    The answers are not simple, and I think it's unfair to blame medical professionals for that.

    If you don't take care of your car and end up spending a ton for repairs, nobody blames the mechanic for your problems. Why blame the doctors, then?

  2. It's something I've been thinking about recently. And I don't know what the solution could be

  3. My first patient in surgical clinics was a 12 year old boy with pancreatitis. It was a pain watching him suffer for our 3 months posting in the surgical ICU and ultimately dying.

  4. You raise the right issues, but where are the answers? In fact, is there an answer to this question? Urja Baggins has hit the nail on the head when she says - "if people don't pay for their own treatment, who does? For the money has to come from somewhere." It is all fine and dandy to blame the "greedy professionals and unscrupulous corporations" for their money making schemes but the best will in the world will not permit a functioning institution to absorb the cost of every patient who has a heart wrenching backstory. Such is the way of the world - sad but true - and realistic.

    However, coming to the other point made by Urja - about a taxpayer funded healthcare system, I must disagree. It may not be fair for a healthy person to have to pay for the healthcare of an unhealthy one but that is the price one must pay for a universal system that treats all equally without distinguishing between the rich and the poor. After all, a lot of people don't hesitate to buy a lottery ticket week after week in the vain hope that one day they will strike it rich, not realising that all they are doing in the process, is making someone else rich by contributing to the winners purse. Like they say, you are more likely to be hit by lightning than win the lottery. But that still doesn't stop anyone.....

    So what is it that makes people buy a lottery ticket? Greed. And what prevents them from contributing to the health service? Selfishness. Both innate human traits.

    The chance that any one of us will eventually reap the benefits of taxpayer-funded healthcare is far greater than that of winning the lottery (or being hit by lightning, for that matter. Or being run over by a train. Or dying in an aeroplane crash.... you get the point.) This kind of system is exemplified by the NHS in the UK or similar systems all over western Europe. None of these are perfect, but then neither is the alternative - as illustrated by private healthcare in the US or the so-called 'free healthcare' in India.

    Coming back to Kamal, at least in his case there is an element of a preventable cause in his case, for which he is to blame. Even sadder is the young patient who has gallstone pancreatitis though no fault of his own or the young pedestrian child who is mowed down by a drunk driver and spends several days in intensive care.

    In Indian culture, there is no question about the family not paying for a relative's treatment. It is an unwritten law which comes from the cohesiveness of the family structure prevalent in the country. They will continue to do so, even when there is no hope. As medical professionals, our duty lies with the patient, not with the family. We continue to do everything we can to prolong the patient's life, regardless of the anguish the family is going through. You can empathise and sympathise all you want but you can't really alleviate their suffering.

    My friends working overseas tell me about the widespread use of DNAR (Do Not Attempt Resuscitation - for the non-medical people among us) over there. The decision to give a patient DNAR status is purely the doctor's decision with no legal obligation to respect the family's wishes, although the family is often consulted to avoid problems later. However, the final decision rests with the doctor and he can disagree with the family and make his own decision. It would be a brave doctor in India to engages in a discussion with a patient's family about not attempting to resuscitate him, especially when this conversation is being held when the patient is still awake and talking - planning for a future event, so to speak.

    Sorry for the long disquisition and I know I have digressed from the original topic. I just wanted to put my meandering thoughts down to paper.

    - The Black Mamba

  5. Sorry about the grammatical errors. I'm not at my sharpest this late at night. :)

  6. Regrading the DNR status, discussed by black mamba, I do not agree-It is ultimately the patient's choice or his family's incase the pt's cognitive status is impaired either acutely or chronically. It is NOT the doctor's decision. Here in the US, there are so many neurologically devastated children and adults, who are on 24/7 chronic life support, without any family-'maintained' as wards of the state.It seems very unfair, but I guess that is a privilege they have being born where there is a system to support them. One day's care often reaches to $1000-for a child without any prognosis or future or family.

    This often frustrates me when I think of what $1000 can do for 1000 children in India or Africa, esp for infection prevention and therapy,but I have realized that I am not the author of life or death,and that disparities such as this will exist.Very unfortunate...

    We do not make the decision of who lives or not, but at least we can help reduce the disparity, by having more insight into medical care and resources that are available in developing nations and start first by reducing wastage of the abundant resources here.[don't get me started on that one!!]


  7. Thank you, Black Mamba, for the insightful analysis. I admit that my point about the issues with taxpayer-funded healthcare system was hastily worded. I'm definitely not implying (although it did come out like that the way I had expressed it) that those maintaining a 'healthy' lifestyle should pay less taxes. That would mean a major overhaul in governance, and I doubt if the world is ready for that yet.

    While I do tend to have capitalist leanings (no, I'm not a b/millionaire!), I'm one of the first to point out that the so-called capitalist system is flawed as it is currently, and requires quite a bit of fix from ideological and logistic angles.

    Nevertheless, I definitely believe that hard-core socialism is evil. It propagates the notion that one man profiting from another's labour is just fine. But that kind of a system, by its very nature, is unsustainable in the long run. It doesn't make everyone rich, instead, it makes everyone poor.

    Why should a self-made millionaire be made to compensate for a poor family where the parents have produced several children when they can barely support one? Why should someone who has generated their wealth by personal hard work, use of intelligence and well-thought decisions pay for another who has made sloth and poor choices their career? Mind you, I'm not implying that all the poor are lazy - I do accept the role circumstances play. But poorly thought choices and decisions ARE major culprits, and I see no reason why people should not be held accountable for their actions.

    Returning to the question of healthcare, I agree, things are not so black and white as my rhetoric. While I would expect the 12 year old child's parents to have saved for medical emergencies, I'm definitely not comfortable with the idea of a child dying because his parents were foolish enough to squander their money over alcohol/other dependencies and went on to reproduce like bunnies.

    What, then, is the answer? I don't really know. I wish I did, and I wish it were that easy. Most of the blog-readers here would probably condemn me as a heartless person, but that's their prerogative. The seemingly heartless people help make the world go round as much as the rest, probably more in many instances.

  8. Thank you for the stimulating discussion. I have no answers myself except the Utopian one - where everyone is concerned for everyone else and love flows freely and greed and pride are shown the door. While the world may never change, I think individuals can - and that can be the starting point. But certainly this system cannot be the right one - although we keep persisting with it!

    I have a lot more to say on the matter, but no creative juice right now, so will return to it later.

    P.S. - UB, calling a spade a spade is never heartless. And btw, you don't seem to have a very good impression of the readers of this blog!! (wink, wink!!)

  9. On the contrary, I have a very high regard for the readers of this blog!

    It's just that I belong to a different school of thought than most people here, and I wondered if expressing some of my views might be inappropriate from that perspective.

    Then, again, what's the fun in a blog (or in life) without some difference in opinion one in a while!

  10. @ Anonymous (Suneeta) - My comments regarding DNAR appertain to the situation in the UK, not in the US. Sorry if I was vague about that. In the UK, if the patient is not in a fit state to indicate what he wants, the doctor has to make the decision for him. The family has NO legal standing in decision making. The physician will take their opinion under advisement for reasons of sensitivity and compassion but has no obligation to carry out their instructions if he thought that their opinion was not in the best interests of his patient. This wiki link explains my point.

    I'm sure that the good old US of A's sword of Damocles (litigation) ensures that families are fully involved in decision making. Right solution, wrong reasons.

    @ UB - That's an interesting tangent you've gone on - Economic systems. A topic that I'm sure AJM will touch on sometime, when the the time is right.

    From my point of view, capitalism is not the right answer. But then, neither is socialism. And definitely not communism. I probably shouldn't talk down capitalism as you (presumably) and I (definitely) are the ones to gain from a capitalist society. However, the western world is currently learning to its cost what a poisoned chalice capitalism can be. It turns out the so called 'free market' is a bit too free. All it takes is for a few footloose and fancy free gentlemen to make a few bad decisions and the world's financial markets come crashing to their knees. So who put these guys in charge? Well, nobody.They don't really need to be in charge to cause worldwide damage. Any mid-level businessman will do. Is this the system for the future? I think not. I think it needs more than a bit of a fix.

    Socialism is no angel either. After all, Hitler was a Socialist - a warped form of socialism but a socialist nevertheless.

    What you're describing above is communism, not socialism. Karl Marx described socialism as "From each according to his ability, to each according to his contribution" and communism as "From each according to his ability, to each according to his need". Socialist ideology indicates that every man takes as much as he gives whereas communism says that you give what you can and take what you need. This is where the lazy profit from the actual contributors. While this communist philosophy might just work in an Utopian society as Marx envisioned, humankind is deeply flawed and greed and sloth will make sure this will never be possible. Perfect examples are Russia, Cuba and North Korea. China on the other hand, uses a modified form of communism tailored to their country, which is why it is successful.

    Like the case of healthcare above, I do not have the answers either, just more questions. A compromise between capitalism and socialism would be the obvious answer but if it were that easy, it would have happened already.

    Btw, AJM my old friend, how the devil are you?

    - The Black Mamba

  11. I just wrote a long post here which has suddenly disappeared into the ether.

    Oh well.....

    - The Black Mamba

  12. @ Anonymous (Suneeta) - My point was aimed at the UK, not at the US. See link below.

    - The Black Mamba

  13. Well written and thought provoking