I headed towards the ER, saw the patient and to be honest i don’t have any first impression. Like a newbie, who I m; I just jumped on to history and stuff and then serially examining things which i had been told about. He had a “tender abdomen, painful left elbow and right forearm and pelvic compression test positive”. Within no time i had asked for a series of X-rays for all regions i was suspecting any trauma. My conscience hit me- can they afford this. This question was forgotten in the hustle bustle of the ER, and i headed to call the Resisdent.
I told him everything I could assess, he asked me were bowel sounds present, and I was mum, why shouldn’t I be. I had not checked for it. Hell; I realized how important was it, because if it were not present – indicates something very critical in the abdomen. I shut the phone and checked for it. My stethoscope on his abdominal wall, and I hear some gurgling at adequate interval. Good I said to myself. Within a few seconds the resident was there.
His first impression, the patient appears PALE. And he orders for a fast NS to be given to him. His assessment does not further add to things which I had assessed. But he also asks for an Abdominal Ultrasound urgently. I was angry with myself for not being prompt. ER intern calls the Radiologist on call; this guy has a peculiarity, he does not come to perform any emergency investigation unless he is been called by any consultant. So now we call the surgery consultant too. In the mean time I catheterise the patient. And then we go to Neuro Surgeons residence to show him the CT Scan head – fronto parietal contusion, with frontal depressed fracture.
Back in the ER we now have the surgery consultant , the radiologist has to atleast oblige now. He does oblige and prepares the machine by the time the patient comes from the X-ray dept. What the surgery consultant was worried about was Hemoperitoneum, so he was asking if there was any free fluid in his abdomen. The patient lying on the trolley, radiologist placed the USG probe on his abdominal wall. As soon as the radiologist says ‘minimal free fluid’ the surgery consultant left. The room was now left with the radiologist, the patient, and...........of course ME. My conscience was hitting me – aren’t we missing a Abdominal CT for him. I got back to ER, and this patient got orders to be transferred to Neuro ICU, with conservative management and neuro observation until tomorrow.
A day later, in the morning patient was complaining of severe abdominal pain. O/E abdomen was tense, tender, with guarding and rigidity. The resident asked for a surgery consultation. During the day I came to know that Dept of Surgery had asked for an Abdominal CT Scan; plain. I was busy the whole day in the ward, and in the evening when I was coming for the rounds I saw the patient going upstairs using the elevator. I wondered what took him so long for a so urgent CT Scan. I was taken to thoughts when I was told that because of money constraints they were not able to clear the bill for the CT. They had gone to village then collected money from all the people and had returned to pay.
Scan reveals – massive free fluid in the abdomen and puemo peritoneum. No wonder the abdomen was so tense. The surgeons immediately asked the patient to be shifted for an emergency laprotomy. The MO wrote the high risk consent, it explained the operative procedure and mentioned that the patient has chances to die on table while operating. The resident took it to the patient party for signing.
I was totally taken aback to see the plight of these poor people. When asked the reason for his hesitancy in signing the consent, he revealed in a broken pitch ‘sir the patient is going to die without operation, but if you say the patient also is going to die on the table, then I don’t know why to sign. Too add up we also don’t have enough money. The resident very calmly explains ‘if he’s not operated he’s going to die 100 %, but the chances of dying while operating are only 5 – 10 %. So don’t delay things further and make a decision quickly. While the conversation was going on, the surgeon got a little irritated and said call me when they sign. Just a moment later the elder brother nodded. And the paper was signed. The surgeon went towards OT saying I am getting ready, send him immediately. The signatory broke down into tears the next moment. The patient still was not shifted to OT for may be another 30 – 40 minutes till I was there, the OT bill master was not cleared. I left the ICU.
This was my first experience with plight of patients with poverty, I was thinking about this for a long time after I came back to room. Later I realized, this is just the beginning and maybe there is another patient worse off than this in stored for me tomorrow. Only thing I am worried about is – I should not get used to, else it’ll make the job emotionless.
