Friday, April 07, 2006

Triage Tales by Dr. Bubbleman

I took this from a blog I regularly read. It’s written by a resident in one of the university hospitals in Manila. I hope Dr. Bubbleman doesn’t mind.

Triage Tales 10

Disclaimer: The following story is a work of fiction. All similarities to people, places, things and events are coincidental by nature.

59 year old patient comes in for epistaxis. Initial blood pressure is 160/100, taken by triage intern.

Patient comes in alone and has her BP taken without fanfare. Just after taking the cuff off her arm, concerned responsible companion (pseudonym Irene Castro) bursts into the ER and asks about her patient.

"What's her BP?"

The intern mechanically answers, "160/100."

"Take it again."

A good 10 seconds passed before it sank in. The intern looks incredulous for another second and then says, "Okay, I will take it later." Presumably after a short rest, as BP spikes are fairly natural after exertion; besides, the reading is more than likely to be the same, making the whole exercise moot.

"What did you say? I did not like what you just said. You will take it again," she points to my intern, "whenever I tell you to. This is supposed to be an emergency, right???"

As I have been neglected throughout the whole exercise, I respectfully turn to "Ms. Castro" and say, "What seems to be the problem, ma'am?"

"Am I talking to you? I'm not talking to you!" (Or, in the more blunt Filipino, Kausap ba kita? Hindi naman kita kinakausap ah!)

Blood rises up. I am red faced. But it is 11PM and I decide that the valorous thing to do is to call my senior. "Ms. Castro" continues to harangue the hapless intern as my ER Officer approaches the triage.

"What seems to be the problem?"

"I just want to have her BP retaken, how much trouble is that? This is an emergency and I need to know if your BP findings are correct... " And she trails off as my senior answers with an exasperated, "Okay, take the BP again."

Dutiful intern retakes BP and reports, "160/100, ma'am."

"Is it the same BP level?" She asks me. "Yes, it is the same level as 3 minutes ago."

She interrupts any further questions with a "Well, I just wanted to make sure, these things happen, lying about BP findings and all. I have to make sure."

"So, what is your next step? Since you don't trust our physical examination findings, this will become a problem for all of us." My ER Officer is adamant.

"Tell me, what is the next step. I am just trying to make sure. All these mistakes happen, you know. I could always bring her to a better hospital..."

My ER Officer is quick to think and offers, "Yes, you do that. I can provide you with a Contact Form so that you can transfer your patient to a better hospital."

"Ms. Castro" felt that she was one-upped by the Triage; fuming, she brings reinforcements, a middle-aged man. His first statement was, "I didn't notice any shouting from Ms. Castro here. Why is it a problem to treat our patient?" Sure, anyone would not notice any shouting from a good 20 feet away inside a tinted sedan.

"Just compress her nose, put some ice on the area, take this Contact Form, and transfer her to another hospital." My ER Officer was accomplishing the form while saying all these.

"Ms. Castro" returns after grudgingly transferring her patient back to the car.

"Let me get your names. I can sue you and place this incident all over the news."

"Sure," I tell her, "just let me get yours too. We will also report you to the hospital director for your behavior."


Some comments. I know that sometimes the non-medical people think the Medical Malpractice Bill is such a bright idea. They better think twice. There are real patients (or more accurately, patients’ bantays) like the one above, sometimes worse. It can really get to even the best and most patient of doctors. And with a Bill like that, it won’t be long before we see Defensive Medicine at its worst in this country (the United States is an excellent example of this system). It will only be to the detriment of the patients, the very sector of society the Bill is trying to protect.


Anonymous said...

Why in the world are members of the medical profession *so incredibly defensive* when questions are asked which they don't expect to be asked??? The ER Officer should not have become so defensive when the companion asked that her friend's blood pressure be re-taken. Friends/relatives of patients *are* under stress when they're dealing with their loved ones in an emergency medical situation. If this member of the medical community had any "people" skills at all, he probably would have realized that after the blood pressure reading was re-taken as the companion requested, the companion would have calmed down a bit and/or run out of questions.

karlmd said...

welcome to my blog, mr/ms anonymous. i'd really like to say 'point taken' but i've had my share of experiences with bantays like these and i really do try to be patient with them. i can't claim that the medical personnel in the fictitious story above tried to be corteous but im guessing he was. being under stress is certainly not a good enough excuse to be rude. trust me, we do try to understand patients and their families. we were taught to do that in medical school. but one can be humanly patient only to a certain extent.

shark said...

In the above fictitious story,

1) staff was courteous
2) responsible companion showed incredibly contemptible behavior and distrust for everything medical that was being done

It's one thing to ask, another to demand something and make a big fuss (read as: pointing her finger, raising her voice) about it.
Hey, I didn't mind at all. Thanks for the link.

karlmd said...

thank you, dr bubbleman, for that clarification. hehe. no problem with the link. keep on blogging!

wickedsis said...

hi karl... the med malpractice bill aims to empower victims of malpractice. in the fictional (fictional nga ba talaga?!) example, the patient's bantay deserves to be tied to a tree and left for the huge red ants... the bill is not an excuse for defensive medical practice. it should instill professional responsibility in those doctors who seem to forget the oath they took before saving (or mis-saving) lives

karlmd said...

it may be a sorry excuse to practice defensive medicine, pia dear, but it will happen. it's already beginning, actually, it's just not as bad as in the US yet. i'm betting, in a few years, at least in the private centers, CT scan (or even MRI) will be routinely requested for the common headache (to rule out the possibility of a tumor), blood cultures will be drawn for all fevers (to rule out sepsis), and GI endoscopy will be done for all tummy aches (to rule out peptic ulcer disease). it will instill professional responsibility but at an expensive cost. doctors will be required to pay malpractice insurance, which in turn they will pass on to their patients, raising professional fees and consultation fees. trust me, it's gonna happen. whether that's a good thing or a bad thing for philippine medicine, it's not for me to tell.

JenMP said...

I don't know how on topic this is, but what I hate about the US medical system is that it's become very money hungry. Instead of actually helping patients to find out what's wrong and get rid of it, doctors throw pharmaceuticals after pharmaceuticals at their patients because of this partnership that they now have with pharmaceutical companies. Either way, whatever efforts are taken to protect one person or group seems to negatively affect another person or group... which in both the Philippines and the US it seems to be the patients. There are too many flaws in the system. There has to be a way to fix problems like these.

Anonymous said...

i wholeheartedly agree that there are major flaws in the system. and pharmaceutical companies play a big role in that flaw. so do HMOs. in the same sense that there are lawyer sharks who lurk around hospitals and look for the next big case, there are also very rotten doctors who are slaves to the pharma companies, or if not the pharma companies, their own pockets. but i'd like to think these are exceptions rather than the rule. that's why it's frustrating for us doctors to find something like the malpractice law hanging over our heads like an axe. let me put it this way. you ideally should have nothing to worry about if you're one of the good guys. but since the law is so open to abuse, similar to how it is abused in the US, even the 'good guys' get bunched together with the rotten eggs (similar to how lawyers are always dumped under the general heading of liars). in the end, the only thing that matters to the lawyer and to the public is the outcome of the case, regardless of the difficult decisions the doctor was faced with. so i really believe in my 'prophecy' that some day, defensive medicine will be practiced in this country, once the malpractice law is put into place. doctors will have to protect themselves and will even go so far as to allow themselves to be slaves to insurance companies peddling malpractice insurance. soon, malpractice insurance will be a requirement to enter any medical institution. there will be guidelines for every procedure in the book and there will be no more room for the art of medicine, for clinical judgment and clinical eye. sounds armaggedonish, but i really think that's where we're headed should this law be put into place. but again, i do not deny that there are rotten doctors who have many victims of real malpractice and real gross negligence and they too deserve such a law to protect them. there lies the dilemma.

karlmd said...

that long anonymous comment right above this is actually me. hehe.

JenMP said...

i was wondering. ;op