In Loving Memory

Quantity

In Loving Memory
I pray I never get so distracted and discouraged by bureaucracy, that I’m unable to focus on what really matters: quality care. (For my patients…for myself.)

I had to get out of there.

It was only the third Mortality and Morbidity (M&M) meeting I’d been to in the Department, but I already knew the script verbatim. Statistics would be followed by the case study which would be followed by the blame game (the nurses blaming the MO’s, the MO’s blaming the interns, the interns reminding everyone that they ultimately did not have final say on these particular patients or that they were a fresh crop that hadn’t been part of the Department yet at the time of this particular incident…) which would be followed by the kind of circumlocution and waffling that would make our members of Parliament envious. It would be about saving face, and self-interest, and carefully orchestrated politics. It would be about anything and everything but the patient.

Already they had spent a good fifteen minutes rehashing the monthly critique about how stats were gathered and represented (“You know, we should probably note ‘Acute Cases’ as a subdivision of ‘New Cases’, because some of new cases come in non-acute…” “Yes, but then what is the cut off for acute? Twenty-four hours? A week? What if they’re referred on a Monday but the ambulance only gets here Wednesday?” “Hmm…let’s discuss…”) and I could tell that we probably weren’t going to get to the case for another half an hour or so.

The meeting itself was only supposed to last about that long, but with all these politicians masquerading as doctors it routinely ran over time.

I got up from my seat and quietly excused myself from the stuffy conference room.

The air outside was crisp, the wind biting at my exposed skin, but I was grateful to be feeling something authentic.

* * *

“How do we get to this point?” I asked myself for the millionth time since I’d started internship. It seemed that everywhere I looked, no matter how hard I tried not to, all I saw were jaded senior doctors doing the bare minimum not to get sued or lose their incomes. Aiming for excellence or at least for progress was a thing of med school days gone by. Yes, occasionally a spark of hope would blossom on the horizon, and I’d get to work with someone who still seemed as passionate and zealous about patient-centred care despite having some grey hair in the game. But it was getting so rare that I was starting to panic that it was a red herring. Very few doctors seemed to care anymore. How long would it take before I stopped caring too?

I’d felt it, that deadening, passionless, zombie-like drive to just get through the ward round or get through the call so that I could go home, turn off my phone and breathe. Every time I caught myself impatiently doing the bare minimum for a patient, I would first feel my face flood with shame because they deserved better…but then it would instantly turn to self-defending indignation–we deserve better.

“What do they expect from us?” I would rage internally. “I’ve been at work since before sunrise yesterday, I haven’t had a bathroom break, a lunch break, a sitting break, a breathing break.” An impatient family member’s screams would pierce the cacophony in Casualty. Threats to call the MEC or the hospital manager because they’d been waiting in triage for hours, as if we’d just been sitting about knitting and not trying to push the line as fast as we could… I’d be seeing what felt like my hundredth patient, and they’d be angry at me because of something some other doctor said or did or didn’t say or do. I would find myself simply staring blankly at the patient, barely processing any words that didn’t relate directly to their presenting complaint because, honestly, my brain had stopped being able to store irrelevant information hours before. “And I’m tired of repeating myself to non-compliant patients. And I’m tired of defending myself from bullies that masquerade as MO’s. And I’m tired of proving myself to Consultants!” I would start to look around, looking for someone or something to answer for how someone who hadn’t slept in over 24-hours was supposed to be able to provide any kind of compassionate, quality care. Patients would glare at us if we so much as disappeared for five minutes to chase blood results, let alone take a nap. “Nobody cares about us, but we’re supposed to care about everybody else! It’s exhausting.”

* * *

My mind had so easily slipped back into that line of thinking–the neural pathway was set, I thought these thoughts more often than I wished to admit–that I hadn’t even noticed that my feet had carried me to an old ward I used to work in. I was about to turn on my heels, when a group of nurses I’d bonded with called out loudly to welcome me back. Some patients who I’d left behind were still in the ward, and they visibly perked up at the sound of my name.

“Dokotela, sowubuyile!” one of the student nurses called out excitedly. I was grateful as always that my complexion had never facilitated the ridiculousness that is blushing, although I could feel my cheeks heat up. I hadn’t meant to draw attention to myself, I’d just been walking to clear my head.

“Hayi, cha, I’m not back, just…visiting,” I invented wildly. “Thought I would come check up on my favourite ward.” It was true and it was false.

Excitedly, some of my old patients started to tell me how close they were to discharge, or how well they were progressing with their rehabilitation, or how much better (or worse) they were feeling.

One patient in particular grabbed my hand and pulled me close so that I could hear her low voice.

“I can’t ever thank you enough, Dokter. I remember how hard you fought for me. I remember everything you did for me. We’ve missed you so much, we talk about you all the time. Thank you. Thank you from the bottom of my heart.”

Now I was certain my skin had burst into flames.

I remembered, so viscerally, the journey this patient and I had been on. I’d been in the ward when she’d arrived. I’d worked her up. I’d diagnosed a latent ailment that raised her anaesthetic risk significantly. I’d hounded the different team members and specialists when they’d dragged their feet assessing her. I’d watched her go from being dependent on the nurses for everything, to slowly regaining her dignity and autonomy. We’d talked, and laughed and raged at the system together. She’d seen me get roundly abused and mistreated by my superiors, and she’d spoken up for me instantly. She’d been patient while watching other patients get attended to and sorted out faster, she’d never once blamed me when patients who’d come in after her left before her. She grumbled plenty–who wouldn’t, it’s a hospital–but we were a team. It was her health and she was my patient, and something about knowing we had a shared goal had lit a fire beneath us both to be as positive and proactive as we could be about getting her home before her 80th birthday.

Then our Consultant had shuffled the internship allocations and I’d been switched, without notice, to a different ward with a different team.

Suddenly that jouney, and dozens others like it, had come to an abrupt end. I never got to see half those patients that I’d left behind to discharge. I hadn’t finished my part of our unspoken bargain. Contrarily, I’d been thrust at a whole new group of patients, and I suddenly lost my will to give my best.

Instead, I’d slowly grown more irritable and unhappy at work. I hated the people I worked with. I hated the conditions I worked under. I hated the general mindset and culture of the Department I was in. I hated everything, and it started to translate into a hatred of clinical medicine. And I’m sure my next batch of patients, directly or indirectly, experienced a different, colder me than the patients in this ward had.

Yet here was this tannie, still in her hospital bed, beaming up at me and thanking me.

I was so humbled. And I was so ashamed.

Part of medicine and medical training’s bad reputation is how militant it is. Things that make no sense in the twenty first century still slip by under the radar because we need to be “hardened by the system to become better doctors” or because “this is how everyone before was trained, so just suck it up”. We’re exposed to such high volumes of patients, both because South Africa’s healthcare system is under-resourced and stretched to breaking point considering the socio-economic conditions that predispose to high levels of trauma and low levels of primary or preventative care, and because a huge part of gaining experience is exposure. We need to learn, so we get thrown into unfavourable conditions with the hope that if we initially sink, eventually we’ll learn to swim.

But what I think often gets dimsissed, is the fact that both the patients and the healthcare workers suffer. Our work can breed frustration, apathy and even depression, but because doctors aren’t really given the benefit of being seen as human, this is often overlooked because patients need to be seen, the community needs to be served, the line is Casualty is getting too long… Any reason to push through is more urgent than the need to have sane, competent, confident, compassionate doctors. As long as the patients get seen and the matron doesn’t get called in about the excessive waiting times, who cares if patients get short-changed? Who cares if doctors develop bad, potentially dangerous habits, taking short-cuts so that they can serve both the patients and not pass out from dehydration and sleep deprivation?

Am I saying doctors should walk out when they’ve reached their limit, even if there is nobody available to take over? No. That would be disastrous. I’m just saying that it’s possible that being forced to push through a haze of physical, emotional and mental fatigue has the potential to be as disastrous. It likely always has been, this is just the first generation to pay more than lip service to the idea that doctors aren’t gods, and we are completely capable of making mistakes.

I don’t have solutions. There’s really no other way to service our country’s healthcare needs. With the current number of doctors leaving either to go into the private sector or emigrating, paired with the relatively low output from our country’s medical schools, there simply aren’t enough of us. And I’m not just talking about the doctors. All of us are overworked and stretched beyond what could be considered sustainable. I have a friend who is a physiotherapist who wishes she could see some of her ward patients daily, but barely gets through her list in a week. There are too few of us, and too many patients. That leaves holes, cracks that patients slip through. And it leaves us stretched too thin to be of any consistent value to our patients. Sure, we make a difference here and there, but in how many instances are we missing or even exacerbating the problem? I often start seeing a patient in Casualty who has notes showing that they’d already been seen (ususally after-hours) multiple times by multiple doctors for similar complaints. But because I’m relatively fresher and more awake, their problem seems so obvious to me that I can’t understand how it was missed. How many patients am I doing the same thing to? How many patients catch me at my worst, at my most exhausted, at my most emotionally drained, and walk away none the better for consulting with me?

* * *

I walked back into that M&M meeting after a good half an hour and deflated at the sight of the same slide still being projected. They were still proselytizing about how they wanted the data capturers to label new patients, which really had nothing to do with anything and was the kind of thing the HOD should have just decided on and kept it moving. I sat in my seat and wrote a note to another intern.

Did I miss anything?

She rolled her eyes and snickered. It was a running intern joke that it was impossible to miss anything in this Department because everyone was always running behind schedule for various inane reasons. Eventually, we got to the case. The usual finger-pointing and vague backside-protecting ensued. The routine about writing better notes was rehashed, although interestingly not accompanied by the proviso that better notes should be paired with better care. The patient slowly dissolved into just another statistic. The meeting ended. Registers were signed. We went back to work.

Hundreds more patients passed through our care following that M&M. Nothing had changed, but I wondered how much more mindfully, how much more deliberately, we were treating them.

I wondered, but it was rhetorical.

I knew.

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Nobody says it because they’re afraid it will imply some element of guilt or liability…but I think too often we shut off our humanity in the face of mortality. I’m truly saddened by this patient’s death. And every death like it. I’m saddened by the way the system fails us all. Rest in Power.
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