Not a Saint Hospital

One morning I found a note on my desk from my secretary. It said:

The Medical Director at St X would like an appointment with you to check that everything is going well for you at St X.

It wasn’t unusual to get a ‘summon’ from the Medical Director of these private hospitals. Usually, it is a low-key chat to make sure that the private surgeons working there are not having issues with the operating theatre equipment or staff, and that they have no complaints about ward care of their patients. It was just over 2 years since I have started bringing patients into St X for my surgical lists so I was expecting an invitation from the MD sooner or later.

I asked my secretary to shorten my next St X operating list, and arrange an appointment with the MD afterwards around 5pm for me.

This was the conversation:

MD: Hi Dr T, thanks for taking the time to see us. So, how’s everything going?

Me: Great. I have had no problems, the theatres are great, the nurses on the ward are helpful, my patients have had no complaints. They are liking the private rooms and….

MD: (Nodding vigorously and leaning forward to cut me off). Well, I want to talk to you about Mrs Y.

Me: Oh? Is she causing problems with the staff?

Mrs Y was a patient of mine on the surgical ward whom I had just admitted two weeks ago. She was a teacher in her late 50’s who sustained severe spinal injuries when she was a teenager and is now wheelchair bound. Mrs Y was also a long term insulin dependent diabetic who unfortunately had severe ketoacidosis last year and ended up in ICU, ventilated for 2 months. During her illness, they didn’t look after her pressure areas so she ended up with severe grade IV pressure sores over both the ischium and sacrum by the time she was transferred out of ICU. She was then discharged from hospital with this problem as no one wanted to deal with it whilst she was an inpatient. Mrs Y went back to teaching, and spent hours every day in her chair. When her blood sugars started to deteriorate and her family doctor noticed an unpleasant smell during one of her visits, it led to the discovery of her persistent pressure sores. By the time she came into my office, she was hyperglycaemic, septic with infection as both pressure sores were wide and deep enough for me to put two fists in each. I could see her ischial bone at the base of one, and the rectum at the base of the other, and because she was incontinent from her spinal injury, the wounds were severely contaminated with faeces as she sat in the wheelchair in her soiled diapers. Understandably, both her and her husband were by now, agitated and frustrated with unhelpful medical staff and hospitals.

I admitted her into St X, because it was a large tertiary private hospital with all specialties on hand. She required an urgent endocrinology review, infectious disease input, a general surgical procedure to divert her faecal output via a temporary colostomy, dressings and pressure care. Needless to say, she started to improve within 7 days. She required intensive nursing care with four times a day dressing change (to prevent accumulation of pus that was continually exudating from the wound) and two hourly turns to prevent development of new pressure sores while she was bed bound.

Mrs Y, at the beginning of the week, cranky from feeling ill and hating being bed bound, was not the best compliant patient. She was a teacher after all and did not like being told what to do. She was also a little distrustful of the nursing staff as it was poor nursing care in ICU which resulted in her current problems. However, after seeing herself improve over a week, she became the most pleasant and grateful patient on the ward. She helped the staff by setting an alarm clock and turning herself so that all the nurses had to do was to pop their heads into her room and check that she was in a different position. She also changed her own colostomy bags so that the staff didn’t have to deal with this particularly unpleasant job. The nurses told me that they enjoyed looking after Mrs Y.

I was rather surprised that the MD had brought her up in our meeting.

MD: No no, nothing like that at all. (He cleared his throat awkwardly). Patients like Mrs Y, well, we find it hard to accommodate them in this hospital.

Me: I know, I know, spinal patients should really be in dedicated spinal units, but there are no private spinal facilities for these patients. Mrs Y has been paying her private health insurance for over 30 years, so she didn’t want to go to a public hospital; she wanted to be looked after in a private hospital.

MD: We understand that, but private health funds in general don’t pay us very much for looking after patients like her. She requires intensive nursing care so we actually don’t get any profit for such a heavy nursing load.

Me: (Speechless for a second) So, let me get this right. You don’t want patients like Mrs Y because her admission doesn’t generate enough profit for the hospital?

MD: I just wanted to make you aware of this, so that you will remember in the future not to bring patients like her into our hospital. We would prefer day surgery patients, but if you feel strongly about keeping them overnight, we are more than happy to accommodate that. As for Mrs Y, I believe you are planning to keep her in hospital for a while?

Me: Yes. At least 3 months.

Both Mrs Y and I had a long discussion about this. She had agreed to take a whole semester out of teaching and come into hospital to have her sores treated properly. This meant bed rest with appropriate pressure care, no sitting in her wheelchair and regular dressings. I had explained to her in depth that if we could make her overall health better, these sores may heal without intervention. If not, they may need an operation. However, even with an operation, she will need to be off the surgical wounds for 6 weeks before she could sit on them. She knew she was in for the long haul, because she didn’t just bring her suitcase when she checked into the hospital, she also brought her Nespresso machine. According to Mrs Y, 3 months was a long time to go without good coffee.

I watched the MD’s face cringe.

Me: I can’t rush the healing process, and I have to wait for the infection to settle.

MD: Maybe you can find a little operation for her so that we can get a little more money out of her health fund during her stay?

Me: But she doesn’t need an operation. She just needs dressings.

MD: We are probably going to lose money if she stays that long.

Me: Would you like me to transfer her to the public hospital? (The MD looked up at me with surprise and a glint of hope in his eyes). I could just say to Mrs Y that St X doesn’t want you here because they are unable to make a profit out of your stay. They think you should really be in a public hospital despite the fact you have paid your private health premiums for the last 30 years…..

MD: No, no. (He started to clear his throat again). There is no need for that. I suppose since we are a hospital affiliated with the church, we can show charity by letting her stay her for a while.

Me: Righto. Is that all? (I started to get up to leave).

MD: But, (he stopped me turning towards the door), if you do a few more of your cosmetic cases here at St X’s, it may compensate for her stay.

He stood up and reached out to shake my hand.

Me: Well, I cancelled two breast augmentations this afternoon because of this meeting. I have transferred them to my lists at another hospital tomorrow.

I ignored his hand, turned to open the door, and walked out of his office without a backward glance.

Mrs Y stayed for the full 3 months and went back to teaching full time, sitting in her wheelchair with a beautifully healed bottom.

 

Living in an Epidemic

When I was reading about the Ebola outbreak last night, I thought of my time in Taiwan during the SARS epidemic. So I went back to the diaries I kept during this time and found couple of interesting entries. I was there as a Fellow in one of the world famous plastic surgery units during 2003. A Fellow is a young doctor who travels to another hospital unit to train for a specified period as a ‘trainee’ doctor, usually to learn from a specific doctor or a particular procedure/technique.

I have left this entry unedited, as it is a true perspective of an Australian living in Taiwan during the SARS epidemic, both as a doctor and local resident.

25th Aug 2003

It’s been more than two months already since the first wave hit Taipei. I still remember the panic that hit the city during that first week; it was when they closed down Ho-Ping Hospital in central Taipei, with all its patients and staff isolated within the hospital. It was constantly being aired on the news and the hospital exterior was being videoed 24 hours a day, a bit like reality TV. There were scenes of flying badmington cocks over the railings of the balcony, and I remembered the presenter reporting that it was great to see that the occupants of the hospitals keeping up their spirits, and exercising to keep fit. The comments from my male colleagues in the TV room at the time were less than polite. I think something was mentioned about there are better things to do when you are couped up with a whole bunch of young nurses. *eye roll*

Then there were news of individuals who were to be isolated at their own homes because they’ve been in contact with SARS suffers. After which, news of non-compliant isolated individuals venturing out of their homes were reported with the police were called to herd them back home. They have now posted guards around quarantined buildings to stop residents from ‘escaping’. Cases were on the rise, another hospital got shut down, and the mortality is starting adding up.

I have missed my chance to go home. Four weeks ago our department director gathered all the overseas Fellows in his office to let us know that if we wanted to go home and leave the country, he would still be happy to write us a certificate for our fellowship and recommend us for jobs back home. There were 7 of us, two from Harvard in the US, 2 from Italy, 1 from UK and another from Ukraine. The Ukrainian and I stayed. It was really a blessing in disguise, because now, instead of elbowing other Fellows out of the way for an opportunity to do cases, we are both operating more than 12 hours a day. I joked to my concerned parents back home that I spend so much time in the operating theatre with its filtered and uni-direction airflow, I am probably at the lowest risk of getting any respiratory virus. They weren’t amused. Wherease my boyfriend just said that if I got SARS, he wasn’t coming to visit. I’d like to believe that’s anger and frustration talking. I can understand why he’s so pissed at me. I think I would be too if our positions were reversed.

The one thing I have discovered about living in this SARS epidemic is that there seem to be more pregnant women than usual at the moment. One nurse mentioned to me that since we have to take our temperatures every day as required for all hospital staff, she has finally managed to get pregnant during her last cycle as she knew her exact ovulation date. A fellow colleague also mentioned that you can pick the pregnant nurses during this epidemic, as they are usually the ones wearing an N95-grade mask. These are heavy duck-billed masks which have viral filters and are very hot and uncomfortable. Most staff members such as myself (who want to breathe and admittedly am a bit blasé about the whole thing) just wear the regular light ones.

Oh well. You’ve gotta learn to see the bright side of life when living in an Epidemic.

Administration has been harping on about wearing the right masks, but I seriously believe that if I wash my hands (which are raw from scrubbing all day), and keep away from sniffling, slobbering people, I’ll be fine. I have been avoiding public transport as much as possible. I have blistered on my feet because it takes me one hour each way, walking to and from work. After 8pm, I just sleep in one of the spare beds in the Burns Unit. I suppose I am like every other deluded doctor at the moment, we think we are being ‘adequately’ careful and probably invincible.

A thought just occurred to me. If I die in this epidemic, I won’t be able to hear ‘I told you so.’

Well, I guess if I am not back tomorrow, you know I am being ventilated in ICU with SARS.

 

 

The Scholarship Kid

The Holistic Wayfarer from A Holistic Journey has lined up a series of stories about money from a selection of guest bloggers. It was a great honour to be invited to be part of this series, writing amongst some of the most interesting bloggers around!

Doctors are the worst patients

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There are plenty of reasons why doctors shouldn’t get sick. The best one being – we make the worst patients. I, of course, am no exception. Despite having had plenty of practice in the past of being a patient, somehow, I just don’t seem to learn. Every time I get sick, I am always a doctor, trying to be a patient.

So why are we such bad patients? Because we think we know better. We are the one saving lives, and sometimes we refuse to admit that we are the ones that need saving.

6 weeks ago, I caught a viral infection, not hard when you work with sick people all the time. I kept working, because as far as I was concerned, if I wasn’t intubated on a ventilator in intensive care, or in a casket, I was not sick enough to stop working.

Reason #1: We don’t realise how crap we really feel until we stop worrying about how crap everyone else feels. When you are deeply buried amongst blood and gore during an operation, you concentrate on what’s in front of you, rather than the tightness and clogging in your own lungs.

Two weeks later, instead of improving, I developed a hacking cough which sounded like I was trying to expel my lungs in piecemeal. As I was struggling for breath whilst talking to patients in my clinic, one of my colleagues suggested that I go and have a chest x-ray done. I did. I looked at it with my colleagues (bear in mind we are both plastic surgeons who rarely ever have to look at chest x-rays), we decided that my lungs looked normal, that I would live and carry on. However, just to be on the safe side, I texted a photo of my x-ray to my husband, who is a lung surgeon, and looks at chest x-rays every day.

Reason #2: For every doctor who self-diagnoses, there is an idiot patient.

I received a text from the husband. Go and see a real doctor. I shrugged it off, he was obviously happy to look at everyone else’s x-rays, but couldn’t spare two minutes looking at his own wife’s x-ray.

Reason #3: Sympathy is sparse when you are married to a fellow medico (and surrounded by friends who are doctors). You have to be showing signs of multi-organ failure before you get breakfast in bed.

I carried on with my afternoon operating list, during which, couple of times I had to sit down because I felt light headed from being short of breath. I felt tired, and was taking more care than normal, but the list went on smoothly without a hitch.

Reason #4: It takes a sledgehammer to slow  down a surgeon. Because we are so focused on our work, we often don’t realise we are pushing our bodies to the limit until we collapse in a heap.

I got home late that evening, at which point my husband looked at my bluish lips, my ashen complexion and yelled, ‘What the F$#@ are you doing at home? You should be in hospital.’ He pulled up the x-ray photo I texted him and shoved it into my face, ‘you have right upper and middle lobe pneumonia.’

Reason #5: When we self-diagnose, we either completely miss the obvious, or become total hypochondriacs with the worst over-diagnoses. In my case, it was the former. Also, note to self- I obviously am not qualified to read a chest x-ray.

I climbed into bed in my work clothes. I couldn’t think of anything more mortifying than going into hospital for a cold and cough. There was no way I was going into hospital for this. So exhausted was I that I fell asleep within 10 seconds.

Reason #6: We never think we are sick enough to seek medical attention.

The next day, as I was doing an early morning ward round, I ran into a friend/colleague who is a general physician. He took one look at me, frowned at the sound of my wheezing and coughing, and promptly declared that I needed to be admitted to hospital for treatment. I told him that I had a full clinic, and will have to check into hospital later that evening. He suggested that I get myself into hospital as soon as possible; I told him that I couldn’t cancel all my appointments and let my patients down at such short notice.

Reason #7: We think that the Earth would stop spinning without us, and that our patients couldn’t possibly survive without us.

The day was particularly long – like a train in slow motion. Several patients looked at me in concern and told me I didn’t look well. I asked my secretary to shift all my appointments and operating lists for the next few days, so I could be admitted into the hospital. Some patients were angry and upset, some complained that they are busy people and already had arrangements in place for their booked surgery. Apparently my illness was going to interfere with their plans. Some were worried that their treatment were delayed and felt that I was neglecting them.

Reason #8: Some of our patients think they couldn’t possibly survive without us.

So I checked myself into hospital that evening. I was put on oxygen, given nebulisers, antibiotics and tucked into bed to rest. It was only when I was forced to do nothing that I suddenly realised how terrible I felt. My chest felt tight, my ribs ached, and my body gave in to the continuous coughing that rattled my bones. My limbs were like jelly and my muscles barely contracted, behaving like useless slabs of soft meat patties. I couldn’t sleep as the call bells pealed throughout the night, sounds of doors opening and closing interrupted my light slumber, and occasional moans and yells from other patients made me toss and turn. The next morning, the physiotherapist spent half an hour bashing on my chest to clear up the clogging in my lungs. We then decided to venture out of the room for a walk, and that is when I saw one of my own patients walking down the corridor on her zimmer frame with her physiotherapist. I looked down at my pyjamas in shame and high-tailed it back into my room. I started thinking about leaving the hospital.

Reason #9: Even though as doctors, we spend the majority of our lives in a hospital, we actually really hate staying in one.

When my physician came to see me, I spoke to him about the possibility of having my treatment at home. He was able to adjust my antibiotics and decided that I could be discharged as a ‘hospital-in-the-home’ patient, where I will be going home with my IV cannula in place, and just come back to day hospital for my IV antibiotics, physio and nebulisers once a day.

Reason #10: A colleague will always assume that as doctors, we would be trust-worthy, compliant, sensible patients. WRONG.

As soon as I arrived at home, I headed to the study and switched on my laptop. I reviewed all my dictation and letters, chased up lab results of my patients and caught up on some bookkeeping for my practice. The day after I was discharged, I had a case which could not be cancelled, so I asked my anaesthetic colleague to remove my IV cannula so that I could scrub for surgery, then to replace it after surgery before I headed back into hospital for my treatment.

Reason #11: We know how the system works and we have connections. Doctors will always find a way to circumvent treatment regimes to suit their activities.

But as I sat there at the end of the day, with the IV antibiotics dripping into my veins, and the nebuliser oxygen mask on my face, I suddenly felt so tired. So tired of it all, of putting on a brave face, of carrying on as if nothing is wrong when I felt so unwell, of worrying about my patients when I should be concerned for my own health, and most of all, I was just simply tired. My bones ached from exhaustion, and my mind was so worn out, it was completely devoid of any emotions.

Mentally, I was waving a white flag. My body was shutting down because it had reached its limits, and it was time I surrendered to the consequences.

Reason #12: It is terrifying for doctors to admit that we, despite our abilities to help people and save lives, are just like everyone else, mere mortals, in bodies that have limits.

After four frustrating, agonising weeks, I am finally on the slow road to recovery. It is only now that I have started to contemplate changes in my life, ways of improving my health, and strategies of looking after myself. In a moment of déjà vu, I felt that I may have been down this path before. Regardless, I was, at last, being a sensible patient.

That is, until next time.