Opinionista Shrikant Peters 8 May 2018

The Patient-Centred Experience – Med Reg

‘Med Reg’, in South African public healthcare parlance, can refer to both a person and a place. First and foremost, a medical registrar is a doctor who is specialising in general medicine, a popular speciality which encompasses a broad range of maladies and misfortunes. I used to think of it as the B.Comm of Medicine. I used to be a B.Comm kinda guy.

When on call, ‘Med Reg’ is the place to which patients suspected of general medical conditions are referred (or if casualty just didn’t know where else to send them). I was an intern in the early 2010s, in Phoenix, to the North of Durban. Here, at Mahatma Gandhi Memorial, the medical patients had always been managed in casualty. The propensity to get lost in the general chaos of the place was high, for both patients and their doctors. Purple luminescent curtains, when not hiding scenes of agony and death, hung off their hooks and swished through puddles of urine and splattered blood. Doctors traipsed up and down the beds, searching for patients to attend to and discharge as fast as possible.

The miscarriages waited forlornly, seated on swaddling blankets wrapped around their waists, the thickness of the blanket proportional to the blood lost. Broken bones and gunshot wounds lined the beds nearest to (but still out of sight of) the nursing station. At least one patient at any given time of day was fighting a losing battle against a faulty ventilator, held together with knotted gauze bandaging. And so it was decided to remove the medical patients from this general malaise to the treatment room at night, hence the second understanding of ‘Med Reg’, the place.

Unfortunately, however, the cold air that breezes through casualty afflicts ‘Med Reg’ quite badly as well. The treatment room is a hollow rectangular space, alongside an open courtyard corridor, with entry and exit points on either end. On balmy Durban winter evenings, gusts of wind blow through stagnantly purulent air, up into the blue lights that shine over the room, and back out the small corner windows, which thrum with the lashings of heavy rain drops. And so my third understanding of Med Reg was as a void; a place of sorrow, exhaustion and desperation – where patients would either be diagnosed in time or not, but were at high risk of death, either way.

Patients are lined wall to wall on particularly busy evenings, requiring shipping container logistics to perform clinical procedures such as blood gases or lumbar punctures. That is if your patient is lucky enough to receive a bed on the main floor for the evening. Otherwise, an army of seated and standing patients hides around the next corner, drip-sets hanging from nails or picture frame hooks in the wall adjacent.

On such a night (weren’t they all, come to think of it), there are generally one or two medical people on hand, seeing patients, viewing X-Rays, performing procedures – until the early hours of the morning, when one’s head feels like it is in a fish bowl.

I was on duty on one such winter evening. Listening to the groans and wailing emanating from each bed the entire night. Having been on medical block for a month already, you learn to quickly block out those who can still speak – they are generally better off already. The unconscious or incomprehensible are far more urgent cases for one’s attention, especially after midnight.

Forgiveness

But on this night – there had been something different. I had been up and down to the wards constantly – fetching the hospital’s only ECG machine, fetching Lumbar Puncture sets, taking DKA bloods, and performing resus after resus. Each time I left the room, amid the angry tut-tutting and head shaking, was a small voice calling out, so easy to ignore. It was feeble mumble, a desperate whimper.

Doctor, Doctor, please…”

I paid it no heed as the clock ran past 02:00. There were patients to be seen, procedures to do. I needed to sleep, but that wasn’t going to happen any time soon. Squares on a page needed to be filled in. My tick-list ruled my life. I fitted in another few quick-draw femoral blood cultures, aggressive lumbar punctures on two very combative incoherents, clerked some basic HIV/TB cases, and gave a stern talk to a defaulter expecting care at this hour. Exhausted at 04:00, I greeted my registrar with a nod and handed over the work that was left to be done.

However, as I picked up my bag to leave the room, that feeble voice was as constant as ever, having plagued my ear persistently; whoever it belonged to was still awake.

Doctor, please help me…”

I looked around the packed room, and still failed to see who was calling me. The voice seemed to be calling out of a corner of that hollow rectangle of a room, behind a drawn curtain. I walked towards it slowly, and stopped outside it. It called again.

Doctor?”

There was a hint of surprise this time, that there had been a response. I drew the curtain back, to reveal two beds squeezed into the space of one. A lady lay sleeping, her hair awry as she was curled up on her side, a drip line pulled precariously from its giving set. Under the line, in the corner, was another body, swaddled in blankets. An arm covered the grizzled face of an old man. He was gaunt and dehydrated. I checked his file – Diabetic, Hypertensive, End Stage Renal Failure, he had been waiting since 09:00 the previous morning, and had not yet been seen.

Doctor, help me,” he exhaled, looking away from me in anguish.

Yes, sir?” I said, “What can I do for you?”

Doctor… I… I want to confess.”

I blinked. “Excuse me, sir?”

I want to confess, Doctor.”

What do you mean, Sir?”

He took a deep breath.

Doctor, I am a Christian, and I need to confess.”

I drew the curtains behind me, and perched myself precariously on the side of his bed. His small, deep-set eyes peered up at me from his blankets. Most of his face was hidden by blanket – as he spoke he covered his mouth with a skeletal hand, ashamed of the words as he formed them. By his age, he could have been my grandfather, yet he looked up at me in fear and supplication. From the smell around him, I could tell that he had soiled himself at some point.

I am a liar, Doctor,” he said, his eyes beginning to well up. I watched his grey eyes blur under the coming torrent.

I shouldn’t be here… I don’t, I don’t deserve to be here.”

Taken aback, I let the silence hang between us, waiting for him to explain. The rain continued to pelt the window above our heads. Everyone else in the room was fast asleep.

I’m not from Durban. I came here from Stanger. The hospital there, they said there was nothing more they could do for me, that I should just go home. So I came to my family, here in Phoenix.”

Sir, there’s nothing wrong with what you have done,” I started, reaching out to touch his arm.

Seeing me move, he squeezed his eyes shut, turned his face toward the bare hospital bed, and started to silently heave and sob dollops of tears. The plastic cushion refused to accept them; and little rivers ran down the bed’s sides and onto the floor below.

I’ve… I’ve burdened my family by bringing them here. They drove me here. And now I’m taking up a bed that someone else could have used. That address on my file is a lie.”

He looked up at the ceiling searchingly.

What will happen to my soul, dear God?” before closing his eyes and saying again to me, “Doctor, please forgive me.”

Patient-centredness

I looked down at the file; it had a Phoenix address on the cover. It was otherwise completely empty on the inside, not a blood pressure recorded. After a full day of waiting for medical care, we had done nothing for this man. And many others have found themselves in a similar situation. It happened constantly, without fail. I just couldn’t take it. The fact that he was apologising, to a system that could not have cared less for him.

The idea of confession is not distant to me (I am a practising Catholic – although I could do with some more practice), and neither of course is the idea of guilt. The feeling pulsed through me on behalf of every worker, manager and politician in the healthcare system that night.

I stared hopelessly at him for a few seconds, pondering whether to clerk him, whether anything I could do as a doctor would make a difference at that point. I decided to pray. I have done this perhaps twice for a patient, and the memory is etched into my brain. I asked him if we could say an ‘Our Father’ together, at which point he nodded slowly through his tears.

I closed my eyes at that point. I do not know if he mouthed the words with me, but secretly I hope not. By the point at which I got to “Forgive us our trespasses” I was really praying for myself and our country’s healthcare system, for what we put patients through on a daily basis. My eyes welled up as I completed the prayer softly, made the sign of the Cross, and etched it across his forehead. Here was a man who refused to judge us as healthcare workers, yet chose to focus on his own supposed sins. And he was in agony. I told him that forgiveness was not mine to grant, but that I believed the Lord was merciful, and quick to recognise repentance.

At that point, before leaving, I asked him for his forgiveness, that he had had to wait for so long to be seen. He looked at me, saw the tears welling in my eyes, and nodded slowly. I promised him that I would see him in the morning after my post-call rounds. I left him then, opening the curtains up to see a litter bin of patients, just like him, still waiting. I thought about each one of their stories. Harrowing. Horrifying. Real.

Another glance at the clock, and I knew I had to leave. I slung my backpack over a tired shoulder, and escaped the void. I never saw him again. Maybe he was discharged. Maybe.

Out in the open courtyard on the way to the on-call room, I noticed the dog-eared posters which the department was fond of plastering over the cracks with. Batho Pele, Sotho for “People First”. I have since seen these in all of the ill-equipped, overloaded hospitals and clinics I have worked in. Among the eight principles that littered the poster were the words “Service Standards”, “Courtesy” and “Consultation”. As it flitted and flickered against the wall in the night-time wind, the words became obscured by the maelstrom.

These ideals are vitally important. We do not spend enough time to understand what they mean, or what this should look like at the interface of patient care. How do we put people first, both healthcare workers and patients – for unless all levels of the system learn to do so, these ideals will continue to mean very little.

I carried on back to the on-call room and got into bed. At least I had a bed – a mattress and a worn-out old pillow. But it was little solace for the ordeal that I knew patients suffered in the void nearby. I laid down my head, and waited for the phone to ring. Fitful sleep is the curse of every doctor, both on call and at home. DM

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