Why do people go to the doctor? They might be sick . . . they might have something broken
that needs to be fixed . . . or . . . they might just want a check up to make
sure that everything is okay (the latter, not very common here). You hope that when you go see a
physician for these various reasons, you will be taken care of, and obvious
things will not get missed. In
residency, I remember multiple occasions on the oncology service (either a new
patient in clinic or in patient consult), where patients who visited their
Gynecologist regularly, had a new diagnosis of cervical cancer. I recall two patients in
particular who were diagnosed with more advanced stage cervical cancer, and had
just seen their gyn within the past year (and told they were fine). For those of you who are not familiar
with cervical cancer, it is a VERY slow growing disease, taking years to
develop. These women who came with
a big bulky tumor on their cervix . . . I assure you was present and ignored at
their last gyn exam.
These types of situations always got to me. Feelings of frustration that something
like this could happen in our country; sympathy for the patient who had been
failed by the system; anger at the practitioner who overlooked such a glaring
abnormality in the exam. Somewhat
similar feelings (albeit emotions that are focused on different causes) to
everything I have been experiencing here.
Yesterday, one of the doctors asked me if I could help him
with one of his patients.
‘I have a 45 year old patient who
has been treated for vaginal infection multiple times over the past 6 months.’
I glanced through her chart . . . it seemed that she had
been seen by every practitioner in the clinic at least once, and was treated
with the same antibiotic cocktail (Metronidazole, doxycycline, cipro) every
time.
‘Has
anyone examined her prior to treating her?’
‘Oh,
no.’
‘Well, it sounds like she needs to
have a pelvic exam . . . do you want me to do
the exam?’
‘Yes,
please.’
I looked past his shoulder to see a very frail woman, hunched
over in pain, barely able to walk.
‘She looks really sick. There is something more going on than a
vaginal infection.’
‘Yes, she has a lot of pain.’
I invited the woman into the room, as Carine
interpreted. Recent weight loss,
awful back pain, leaking of fluid from the vagina. She took her underwear off, which were obviously soaked in
urine. The whole room smelled like
death. We helped her up on the
table, and I started the exam.
Carine asked me if I wanted a mask . , , I declined. As soon as I inserted the speculum,
large amounts of urine mixed with necrotic tissue pooled into the visual
field. I removed the
speculum. My bimanual exam
revealed a large fixated mass, filling the entire pelvis, most likely extending
into her sacrum, obviously invading her bladder. Stage IV. The
worst I’ve ever seen.
This poor woman walked 10 hours that morning just to get to
the clinic. She was alone. She had been seen at 6 different
hospitals for this same problem (including a PIH hospital), and I was the first
person who performed a f***ing exam.
[I realize that my anger at this example of piss poor patient care isn’t
going to make a difference, but you reach a point where you can’t just say . .
. ‘it is what it is.’ No one would treat someone for hypertension
without obtaining a blood pressure, why is this any different. Is it so much to ask for people to do
their job . . . EXAMINE THE PATIENT . . . or refer her to someone who will.]
As we do not have any po narcotics here, we made the
decision to admit her over night for pain control. Last night, one of the doctors came to my room to ask me why
I had her admitted, and why I wasn’t going to operate on her. I explained that things were not so
simplistic as ‘take out the tumor,’ it was invading too many important
structures. After what felt like a
long argument, he finally succumbed to the facts provided by the
specialist. I about lost it when
he told me that I needed to put her on antibiotics for the smell. [I also think the concept of palliation
is foreign to some people. We are
still trying to get some type of pain medication for the woman to go home with
(while she is here, she is getting morphine), and people have been arguing that
we need to send her home. How
would you feel if you had a big tumor invading your bladder, and taking over
your pelvis? . . . have some damn compassion!]
Last night, Carine disappeared downstairs for a little
bit. She was bathing the patient,
cleaning her clothes, and feeding her.
I almost cried. In the
midst of such a shitty situation, knowing that there are such amazing people,
with so much compassion helps you see how much good is capable of existing in
humanity.
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