Omission

It started out like any normal day in the emergency room. Nothing out of the ordinary. Managing patients left and right. Writing down orders. The occasional cardiopulmonary arrests break down the monotony. Then someone came up to me, his face vaguely familiar. Was he a patient on follow up? He spoke some words that at first i could not understand. He seemed really upset, even angry. It took me a few more seconds to realize that he was blaming me for something...

He said his brother, a patient that I managed in the emergency room, died two days after being discharged from our hospital. And he was blaming ME for his death. Saying that we did not attend to his brother, that we basically just ignored them, that's why they were forced to leave--- because apparently staying at our hospital would bring them nowhere. That's his version of the story. I took me a while longer to remember his brother's case. With the number of patients we see everyday, faces have this tendency to blur.

They sought consult because of a carbuncle on his right buttock. It gave him great discomfort because it was very painful every time he tried to sit down. At first we directed them to the outpatient department because clearly such cases aren't managed at the emergency room. But since he looked weak, we decided to give him some primary treatment. Upon closer inspection, the patient was febrile, and he had yellowish sclerae. He was probably septic. The carbuncle, his primary complaint, was probably the result of a system wide infection. But since there were very limited ancillary procedures available in the God forsaken hospital where i am employed, I couldn't really pinpoint where the source of infection was. Empirical treatment seemed to be the only option, as always. But since the antibiotics of choice were not available in the hospital, we had to ask the relative to purchase the antibiotics in one of the drugstores outside. That's the first stumbling block that we couldn't seem to hurdle. The money they brought with them weren't enough to purchase the medications. If only the medications were available, then they could just opt to pay for the meds prior to discharge from the hospital. Sadly, such a scenario remains to be a dream in most government hospitals.

The second stumbling block--- the patient can't be admitted because there's no room available. Because he was septic, it was not advisable fro him to stay and wait at the emergency room when there's no certainty as to when he would be admitted. In the emergency room, patients with various infectious diseases are placed side by side. Prolonging his stay in the emergency room would only worsen his condition. We had no choice but to advise them to transfer to another hospital where adequate treatment would be given. I was about to explain this to them, when the patient's brother told me that they decided to go home instead, because they would be leaving for the province the very next day. I told them that it was not advisable to go home. And he was definitely not in the condition to travel. I specifically told them that they should transfer to another hospital. I thoroughly explained his brother's case, but they were stubborn. They said they already purchased tickets for the trip, and they have to back to the province the next day. They would just seek consult at the provincial hospital. I told them that if they would insist on what they want, they should sign a waiver that they want to be discharged against medical advise. They agreed. It was against hospital policy to give a referral form when patients decide to go home against medical advise, but I gave them a referral form that they could show to another doctor when they decide to seek medical consult. The patients vital signs were stable, and though he was weak, he could still walk. I signed the discharge papers saying it was okay for them to go. That was two weeks ago.

And then the patients brother suddenly showed up, accusing me of negligence. Accusing us of being numb. Saying things like just because they are poor we didn't give them the necessary treatment, making the whole thing case of oppression, a clash between socio economic classes. What did they expect us to do? Shell out money to but the medications outside? If we did that to one patient, shouldn't we be doing the the same thing to each and everyone of them? If I had enough money, maybe I would have done that out of pity, but I certainly didn't have enough money to buy medications. Just because we are doctors doesn't make us martyrs. Sure, we could be martyrs if we wanted to, and I have been a martyr several times in the past. But in reality, doctors couldn't afford to always be martyrs. Majority of doctors can't afford to be martyrs at all. And it's not like I gave them faulty advise. I kept on reiterating that they must transfer to another hospital, they should not go home. I explained the possible consequences. I kept on explaining this to the patient's brother and he can't seem to understand. It even seemed as if he suddenly had selective amnesia, completely forgetting the preliminary treatment that we gave, forgetting the fact that i was persuading them to transfer to another institution, completely forgetting the fact that it was THEIR choice to leave. I kept on explaining and yet it couldn't get through his thick skull. He kept of blabbering the same things, keep on sputtering those accusing words, and my patience was slowly running out. I decided to look at the other patients before I said anything I would probably regret later on. I could still see him at the corner of my eye, just standing there, as if waiting for something. I had no idea how long he was waiting. I just realized that after some time, he finally left.

I know i did what was needed to be done. I managed his patient properly. I know I wasn't negligent. I am not guilty of the sin of omission... but why do I feel a tinge of guilt? A few hours after he left, when the work load became benign, my conscience started bothering me. Did I do something wrong? Was there something more I could have done? Maybe all I felt was empathy that I've mistaken for guilt. I could feel the deep sadness as I looked into his eyes. I could feel his pain. I could feel his loss. I could also feel his frustration... hopelessness... futility... anger. Anger brought about by loss. Misplaced anger brought about by a lack of understanding. And with the amount of anger that I also saw through his eyes--- even an innocent man would probably feel guilty with such a hateful gaze directed towards him.