Who is a WITCH?

One fine morning, I received call from a hospital where I do my private practice. They asked me to come hospital to see an emergency patient there.

I reached emergency in few minutes. A gentleman was sitting in emergency tool. Our paramedic who had done primary management, told me that there was simple case of physical assault brought by police, and police were waiting outside to arrest him after we discharge him from hospital. He further suggested me to admit him in hospital which will save him from torture by police, and further it will be economically beneficial to hospital as well. (Let me remind that such request is not unusual in private health centers, further requesting for admition and expensive labs/meds and huge bill is also not unusual by patients of physical assault since the assaulter will pay for the bills.)

I took a quick history from patient, he said he was beaten badly and is having severe pain, and requested me to admit him in hospital to do necessary treatment and pain management. His examination findings were normal. His anxiety made me feel that I should admit him. I sent an Xray to rule out bone fracture.

I had to wait for sometime till report of X-Rays comes. In this leisure, I asked helper-boy of hospital about why police were waiting outside. He said, “Sir, the patient you are seeing is famous politician from major political party. His daughter is sick since few months due to a witch-craft (बोक्सीको जादूटुना). Thus they beat the witch and her family. The beaten family is under treatment in nearby hospital.” He further gave his view that witch should be treated exactly like this.

“If there was something called witch, no terrorist would use suicide-bomb. They would rather come to our villages to learn the witchcraft and kill or injure the people-leaders they want without any difficulty.” I said. I had grown little angry myself knowing that my patient has accused some one of being witch and has beaten her innocent family for no reason.

Photo of Kantipur Dialy
of news on same issue

Report of x-ray came in few minutes showing normal findings. I prescribed the needed medications and informed the police that they can take him away now.

Not only friends in hospital, but also few of my close well wishers were not happy for what I did later. They commented that helping political people is relation of give-and-take. It would be beneficial to me later. They further warned me that in current society, there isn’t good place for a person who only does what he thinks is right. Being ethical doesn’t pays, instead it harms.

I silently disagreed.

In the evening, there was news in “avenues tv “ about same incident, that the culprits are arrested. Next day, I read in national newspaper “Kantipur” and the “Nagarik” about same. All of them made me feel that, if had really helped him to escape from police, I won’t have been able to forgive myself.

At the end, it’s not about what my gain is, it’s only about what type of person I ought to be….

My ethical case presentation

Photo: Google

Medicine is profession with full of dilemma, what should we do? What we should not? There are questions with no appropriate answer. Risks and benefits can be calculated on relevant guesses yet it can’t be final. Let me give you some of examples-

• What should we do when a man ask not to tell his mother that she has cervical cancer because she won’t be able to bear this bad news? There is no medical evidence to prove her inability.
• Should a patient in extreme high age (say 90 years) and with some chronic problem be admitted in ICU? We have very less numbers of ICU beds and plenty of patients.
• Should we resuscitate a dying patient? He will die anyway. Prolonging his life for some more makes him suffer with pain for some more time.
• How to proceed when a HIV positive women denies to tell her husband or call him in hospital?
• What to do if a patient demands a whole body CT scan or abdominal Video X-ray (USG) without any medical indication (need)?
• What should a senior doctor do when a staff of hospital comes demanding to see him immediately when a long queue of patients are waiting their turn since 5 hours or so?
• What should we do if a patient wants to go signing form of LAMA (Leaving Against Medical Advice) because of not having money to get treated? Etc. etc…

These questions have no appropriate answers.  You are correct by both the way. You need to act on best possible option for the patient and sometime for the population. Skill of taking right and timely decision develops with experience.

There are things at PAHS which I simply find wonderful. One among them is exposing students to such ethical dilemmas by making student write a log on ethical cases so that they can handle those ethical issues appropriately. We have 8 weeks posting in each major department during junior clerkship of 3^rd year. During these eight weeks, students have to write log proforma of eight patients out of which at least one should be an ethical case. We have to write the case and interpret it. The theory part of ethics is already taught in initial basic science years.

The cases student select are mostly interesting and informative. We come up with several issues like- doctor scolding a patient with words like “त डाक्टर कि म डाक्टर?” i.e. are you doctor or I am? Then who should decide? Other issues like doing a Lumbar Puncture (that is taking out of CSF fluid from the backbone for investigation) without consent or permission. Doing surgery without appropriately giving anesthesia. Missing some problems because of inadequately examining etc. out of all the ethical cases one is to be presented by each student individually, that is marked and added in examination.

Recently I too did my presentation. The associate professor who was marking is a very inspiring faculty. He gives feedback very logically. He always starts with positive feedback and in the end gives few suggestions in constructive way. Five of us presented that day. After we presented the concerned faculty admired us saying, “I am myself learning new things with each presentations student make.” He added, “In the initial days, I used to search where can I add some marks for student, but now I am searching where to cut off some marks, but I don’t find it at any place.” His last sentence really made us feel happy when he declared that he has given full marks. I need not say, marks always counts in student life.

All the presentation was good. Let me tell about my case.

A baby from a village of Saptari, with no ANC visits and delivered at home started to have problem in sucking and breathing, he was taken to BPKIHS Dharan, where VSD (a defect in valve of heart) was diagnosed and referred to Gangalal Heart Centre, Kathmandu. The baby was receiving lasilactone (a drug) which was prescribed by Gangalal Heart Centre for VSD.

Patient party were in Kathmandu for operation at Gangalal Heart Centre. Baby was sent to our hospital for respiratory problem. He was admitted and treated adequately. During hospital stay, mother was advised to stop all the medications and nurses were giving medications as required. The baby got well by 10 days and was discharged after recovery. He was provided with the same drug given by Gangalal Heart Centre. Before leaving, patient party asked with nurses, “If they should continue medication given from Gangalal Heart Centre or not?” 

Nurses advised to take them. As a result, patient was taking double dose of that drug. Within 2 days, baby developed complication, and was brought to emergency. During history taking baby getting double dose of a drug somehow went unnoticed.

During history taking in night call, we, medical students found this and informed the duty doctor. She corrected the error then and there. They were lucky that medical students were assigned for them.

During discussion, I brought up series of things about ethical issue.

This was medical negligence (willful negligence) by discharging doctor who didn’t properly talked to the patient during discharge. There was error of omission (i.e. not doing something you are supposed to do) by treating doctor who asked to stop the drug from other centers but didn’t explain when to resume it. The nurse suggesting to starting medications from Gangalal Heart Centre was also an error of commission (doing something you are not supposed to do). The conclusion was, ethical principles- beneficence (i.e. do good) and non-maleficience (i.e. do no harm) were breached. I was also not satisfied to the duty doctor whom we informed about the error. She corrected the mistake and counselled the patient. But didn’t give feedback or warning to the concerned hospital staffs.

There were also some social issues, associated with the case.

The poor family find hospital stay and canteen charge to be costly for four of them thus those days were being big burden for them. The 5 year old elder sister was missing her school, who came here with parents for the treatment of brother. In village, everything was being messed up. They have asked the neighbours to look after their cattle (cows, buffaloes and oxen).  And It was rainy season then and they were worried saying “धान रोप्न पाइएन” that is they couldn’t crop their field, this might cause trouble to eat for the whole year.

This was all the case about. I hope it was interesting and you must have got somewhere more aware to your surroundings.

By reading this case, you might have thought that medical personal are mostly negligent. And they don’t take the patient’s issue seriously. Then that’s not true. The case I presented was one of the very rare events. And if I had not found it, someone else would have. And even more, Patan hospital, our teaching hospital is renowned for its ethical practice, giving good information to patient, working for poor and underprivileged people. Let me tell you, the social service of this hospital has its yearly budget of more than a crore (10 million). The canteen charges are less than a half compared to simple hotels outside the hospital. This public hospital is patient friendly in all respect except that it is highly crowded thus rich people would hardly like to come here. Even if they do, they come to private clinic of this hospital which charges them comparatively high. And again the income of private clinic and private wards are used in social service of the hospital for poor who can’t pay.

Obviously, Its a proud to have a privilege to be associated with such a medical school and hospital, with high morals.

Ethics II: The periphery inside valley

Photo: Bing

Last time I talked about some malpractice I have seen in middle of valley. Today I am talking about an experience of mine from some peripheries inside valley.

I was in a small hospital at Thankot, Kathmandu, for some of my personal work. I knew that the owner of this hospital forces the doctor to prescribe unnecessary and costly drugs and lab investigations. The doctors even do it.

On the list of doctors in notice board, name of a senior surgeon and a senior gynecologist from our public hospital was present in the top of the list in big font size. I was surprised, what does a surgeon do here, in a hospital without Operation Theatre. And what would a gynecologist do in this hospital without even a delivery room.

The owner of the hospital was quite friendly to me. So I asked him, “Do these doctors from such a big and busy Hospital really come here, or u just have kept the name for advertisement?”
His answer was unexpectedly shocking. He said, “Obviously they don’t come here. But at least I know them. There are plenty of hospitals around who have written the name of senior famous doctors whom they don’t even know. Sometimes, when those doctors accidently see their names, they are themselves surprised and say How come is my name and NMC number here?”

I could react in no way other than laughing.

I was in the staff-canteen of same hospital. An old man, who was friend of the owner of the hospital, was sadly telling the story of his daughter to my brother. I too was interested in that story. He was telling that he is treating his daughter in this hospital from more than 2 year but she is not getting treated. The history of problem was not so specific. I could not come to any diagnosis at all. In the end I just advised him to take his daughter to a good hospital. I advised him that Bir hospital, TUTH and Patan Hospital are some good tertiary care centers and you can visit any one.

Soon after that conversation, I had to leave. Later on I came to know that, the owner went angry on me. I had referred one of his patients who come every2-3 weeks to his hospital and spend few thousand of rupees. It was like a दुहुनो गाई (means source of permanent income) for him.

It’s ok to earn, but how can someone do this in a risk of health and life of some one? Does he even know, what is being happening? I closely saw how people kill their own humanity for money.

Ethics…

Imagine a young guy of around twenty years old. He has some pus under his skin in legs in the form of abscess. He goes to the oldest and most renowned hospital of Nepal, The Bir Hospital. Let me tell you, Bir hospital is good and well facilitated hospital with plenty of doctors of different level. They can manage almost all health problems which is manageable in Nepal. And that young boy with abscess in leg, need a minor surgery called Incision and Drainage (I&D). I&D is a very common and simple surgery that can be easily done even in resources poor setting. He went to Bir Hospital, a well facilitated hospital. So we can assume that he got a good care and was treated there easily.

Unfortunately, story didn't go like this in reality. I have heard that many of the patients reaching Bir hospital are not treated. By a means or other, they are force to go to nearby private hospitals. Most of those private hospitals are owned by doctors of Bir hospital, and are opened to make plenty of money. Similar to many other patients, this young boy too was also (forcefully) referred to one of the nearby orthopedic and maternity hospital. The orthopedic department, who manage disorder of bone and joint, admitted this boy who is a case of general surgery department. I don’t know was this right to do, but since I&D is very simple operation, they have an expertise to do it.

What I want to talk about is a different matter. A hospital staff asked the orthopedic doctor,” How much should the boy pay?” 

The doctor answered, “Take around 15000 or 16000 ( पन्द्र-सोर्ह हजार लिनुस् न).”

He made a bill of sixteen thousand and handed it over to the boy. He was a student and this was big amount for him. He phoned someone of his family in village and said in a very sad manner, “I am very sick, I am planned for operation in hospital. It cost sixteen thousand, I don’t have more than four thousand rupees. Please send me money as soon as possible.”

The poor family somehow managed the money for their very sick (they think) child who need operation. And I&D was done the next day after he deposited the money.

Now let me tell u. In a public hospital, the charge of I&D is around one thousand. I’m sure it’s even more cost effective in Bir hospital. And this guy was not economically sound to pay this huge amount. But who cares. I don’t think if these doctors ever knew what ethics is, what professionalism is. Let me add, the charge of normal delivery in that private hospital was about seven times more than our public hospital. Cesarian-Section (The delivery of a fetus by surgical incision through the abdominal wall and uterus) cost about 10 times more.

I came to know about this story because a close relative of mine used to work in that hospital in very very low wages (say volunteer). I’m sure he must be unsatisfied for his job that helped those sinners who suck the poor.

This hospital is just an example. I have heard from different means that, there are plenty of such hospitals around Kantipath and Putalisadak that runs as unethically as possible. And patient for them is managed/sent by the Bir Hospital. Many of the patients are over treated. All of them are over charged. Many of them are made to stay in ICU which is not required (no medical indication). An ICU bed costs about five thousand per day, which is a huge amount. Moreover, these hospitals are under facilitated and resource poor. Even ICU, which should be run by an intensivist, are run by nurses. I am not blaming everyone. There are many hospitals running ethically and professionally. But malpractice exists, and has crossed its limits. I hope government, system, medical council would woke up soon and take action. Few years back, the Tribhuwan University Teaching Hospital (TUTH) also called IOM, at Maharajgunj was also similar to Bir hospital. There always used to be few ambulances of private medical collages and private hospitals in the parking of TUTH to take patients of TUTH to the private hospitals. The Emergency doctors of TUTH would lie saying ward is full and refer the patients to Private ones in the greed of commission. Thanks to Dr. Bhagwan Koirala who stopped this after being hospital director of TUTH. Many senior doctors tried their best to kick Dr Koiralaa out of that post. Fortunately they didn’t succeed and TUTH is fine now.

Talking about this made me remember about recently published news on corruption. Transparency International, a NGO that lead global movement against corruption, recently reported Nepal to be 36^th most corrupt country of world. Political parties being most involved in corruption, followed by bureaucracy, parliament, judiciary and army in the fifth. 

I was wondering, in the hierarchy of corrupts, where do doctors and medicine stand??

May be its not there because doctor’s profession is still not that bad and corrupt. There are plenty of doctors and medical personals who practice justifying the trust of common people on them. Who show respect for human life and whose practice meets the expected standards in all domain.

Another more Probable reason is, may be malpractice in medicine is not commonly seen or understood by common people, so it remains unreported. 

I hope the former one is correct…..

I hope these malpractices would be controlled soon. There must be some problems of doctors as well. The medical school charges being too high, salary of them being too low, higher study being too expensive and unaffordable, etc. I hope even those will be addressed.