Excerpt#48: VIPs - Very Important Patients

Excerpt # 48:  VIPs - Very Important Patients

I was asked by Mr. Bhattal to consult on a VIP patient in the Intensive Care Unit. He did not need to be there except for the fact that he was a VIP, a senior appellate judge. Except for the royal suites, the ICU is the only place where you have private rooms for patients. I saw him poring over his legal papers, and on seeing me he quickly gathered them all up and turned them over. Later I discovered that he was preparing his judgment on a major corruption case involving a high-profile national figure in the ruling party.

         This judge had a toe infection. That is usually a minor affliction, more a nuisance, except in diabetics and others with compromised immune system. He was about to show me his recalcitrant ‘minor’ wound when I stopped him to ask a few questions, focusing my query on the status of his circulation not only to his legs but also elsewhere, as well as for symptoms of nerve damage from his diabetes. Even though I tried to be as clinical and detached as possible, he was discomfited by my queries. He was a busy judge and had an important decision to write, and this young surgeon was enquiring about his sex life! I had to explain more than once why the answers to my questions were important. As it turned out he had severe circulatory impairment, and not just to his toes.

         He thought he had a minor toe infection and all that was needed was to clean and dress it up, plus some antibiotics. What was the big fuss? He reminded me of a severely anemic society lady I saw in GHKL who wondered why I could not diagnose her malady right away, like all her previous doctors, and had to do all those tests. Give her the iron pills and vitamins that she sought and be done with it. I had to explain to her the multitude of causes, from simple worm infestations to more serious stomach and colon cancers. She felt insulted by my reference to worm infestations, implying that she was from the rubber estate walking barefooted every day. Only with my mentioning cancer did she begin to take me seriously. She turned out to have the rare pernicious anemia, a major risk factor for stomach cancer.

         Up till recently most patients were afflicted only with acute illnesses. Modern medicine has been truly miraculous in treating those to the point where physicians are viewed now simply as human mechanics, highly skillful to be sure but mechanics nonetheless. Check me over, order a CAT scan or MRI, remove or fix the defective part, and let me carry on with my life.

         Today most diseases are chronic, like diabetes, where there are no cures, simple or otherwise. We have to instead learn to manage or at least keep it under control for as long as possible and with minimal interference to our daily lives. The physician’s role is less a healer, more a teacher. Indeed, its Latin origin, docere, means just that. At that moment with the judge I was not a surgeon but the true original physician, a teacher. I was trying to educate this judge on his chronic condition.

         One way to gain patients’ rapport and also to gain their confidence, as well as to reassure, is to tell them that you have seen worse, or that their condition could be worse. I told the wise judge that diabetes affected all organ systems.

As a student, my professor used to tell me to know syphilis “cold” (thoroughly), as it affected all systems. Whenever I was asked during orals about the differential diagnosis of any sign or symptom, I was reminded to always include syphilis, and utter it with some noticeable hesitation. Then when you were queried further, as your examiner had been lured into interpreting your hesitation as a sign of uncertainty, you could then show off your mastery and impress him! Syphilis is today readily curable and no longer a menace. Instead we have lupus and diabetes. Lupus is rare; diabetes, not so. Know both and you know medicine, my professor advised me. Or at least be well versed for the orals!

         I expounded to this learned judge the systemic nature of his disease and that the toe was only one manifestation. He was lucky that it was the circulation to his toes that was affected and delayed the healing. Had it been to his heart, he would have a heart attack; to his brain, a stroke; eyes, blindness; and kidneys, kidney failure and be on dialysis.

         That grabbed his attention. Because of the nature of diabetes, his legs and indeed his whole body was high maintenance. Meaning, watch his diet, discontinue smoking, regular exercise, and faithfully take his medications. As for his legs and feet, he had to examine them every day, wear thick socks and well fitted shoes. He could no longer rely on his physical sensations as his nerves were now damaged.

         That judge was not expecting a lecture from me; he expected me to change his dressings or do only some minor cutting and trimming while he deliberated on his important written judgement.

         I learned my lesson on dealing with important patients early in medical school. Our dean, Dr. Walter C Mackenzie, had an inherited condition of his bowel that required regular surveillance. He was admitted once to our hospital and I was the medical student assigned. Prior to that my chief resident John Irwin warned me that the dean was very particular that every step be taken and there be no shortcuts or he would let you know in no uncertain terms. I had to insert a tube into his stomach through the nose, a routine procedure that today would be done by nurses. To an unsure medical student however, that was a monumental task, especially when the patient is somebody important like your dean. I was tempted to call my senior, either the intern or resident to do it but would risk getting de-meriting remarks. Remembering my chief resident’s advice, I did it myself, treating him like any of my other patients. I had no difficulty as he was the most cooperative.

         It was this temptation to breach routine and take short cuts in the misguided notion to “spare” patients some discomfort or embarrassment in dealing with “special” or important patients that could lead physicians and surgeons astray, as demonstrated by the near tragedy of the circumcision of that VVIP’s son in GHKL a year earlier.

         Likewise, concerns with niceties or professional etiquette would get in the way of good patient care. I was making rounds in the ICU one day when I saw a patient’s x-ray on the viewing box. Something ominous about the image made me call the patient’s physician, an Ob-Gyn man, and I told him of my suspicion and the need to operate on the patient right away. He replied that he was consulting with his senior colleague on that case. I left it at that. It was a case of a botched backstreet abortion, with all the radiologic signs towards a catastrophic outcome.

         The next morning, I was again making rounds and noticed the bed empty. She had died. The surgery was unnecessarily delayed and with a fatal outcome. I should have been more forceful to my colleague. I would not know whether that would have altered the outcome, but at least my conscience would have been clear.

Next:  The Gratitude Of Plastic Surgery Patients

Excerpted from the author’s second memoir, The Son Has Not Returned. A Surgeon In His Native Malaysia, 2018.