Of Least Concern

Another day in the emergency room. Usually exhausting, at times benign. Always unpredictable.

It was around 9 PM when those two stab wound patients came in. I've encountered a lot of trauma patients, and I have been trained regarding the proper management of such cases. Both Patients were hypotensive, but one of them already has parts of his intestines eviscerating from the stab wound on his abdomen. And he had a lot of other stab wounds on his back, which could account for the probable massive blood loss. On ausculation, his lungs didn't appear to be injured, but I ordered an immediate chest x-ray just to be sure. An emergency exploratory laparotomy was indicated. The other patient only had a single stab wound. Auscultation revealed a possible pneumothorax, but since he was more stable, i first administered fluid resuscitation and ordered an immediate chest x-ray.

While waiting for the results, i referred both patients to the surgery consultant on call. I was surprised by his response. First he asked me if there was a vacant room available. I told him there was none. He said how can the patient be admitted at the hospital when there's no available room. He reminded me of the "no room, no admission" policy. i told him in such emergency cases, a patient can be admitted even if there's no vacant room. Then he told me we lacked supplies at the operating room, and I said I already checked the supplies at the operating room. The hospital did not lack the necessary supplies. Then he said that he would need blood for the operation, and without waiting for my response he told me that's it's better to just stabilize the patient and transfer him to another hospital as soon as possible because we cannot operate on the patient. WTF?! Good thing one of the nurses had the foresight to check if we had available blood at the blood bank, so I told him that blood was available in case a blood transfusion was needed. Then this surgeon sounded irritated. Even more when I told him that I could do the operation for him if he would allowed me. He ran out of excuses, so he just told me he'll be at the hospital in thirty minutes.

Searching for an anesthesiologist was another problem. I already called all the anesthesiologists on deck at the hospital. Some said they had an ongoing case, others said they were out of town and that they wouldn't make it in time for such an emergency procedure... but i doubted if these anesthesiologists were telling the truth. It has always been such a chore finding an anesthesiologist in a government hospital. The others simply didn't answer their phones. I had no choice, so I just called their department chairman and told him the situation. I told him bluntly, if he can't find an available anesthesiologist, he had to administer anesthesia to the patient. I didn't care if he found me disrespectful. A patient's life was at stake, I've had about enough of these consultants and their stupid excuses.

The x-rays were done after that. The patient's chest x-ray was unremarkable, but the other patient had a massive pneumohemothorax on the left side. And whereas previously he didn't find it difficult to breath, after the xray he was almost gasping for breath. So I did an immediate closed tube thoracostomy without referring him to a consultant. It was an emergency and I've done the procedure dozens of times, so I didn't bother informing any consultant. Several supplies were not available, but miraculously, I managed to improvise. Afterwards, the patient became comfortable, although he complained of pain in the left lower quadrant of his abdomen. Palpation of the area elicited tenderness. Since the stab would was on the lower ribs, an abdominal injury was possible. I could have done an abdominal ultrasound to rule out an intraabdominal injury, but it wasn't available at the hospital. The chest xray didn't show any signs of pneumoperitoneum, so I decided to just observe the patient. An exploratory laparotomy could also be indicated if symptoms progressed.

And then Mr. Surgeon on duty came. He ordered the nurses to bring the first patient to the operating room ASAP. I mentioned the other patient to him, and that I already inserted a chest tube. He didn't seem to care, but when I told him about the abdominal findings, he told me to transfer the patient to another hospital while it was still early, because there's no way he could do another laparotomy. Christ. Is he aware of how difficult it is to transfer such a patient? Especially when the mentioned patient lacked sufficient funds? I can't just transfer a patient when I have already managed his immediate concerns. Most government hospitals already have their hands full, and they would not be inclined to accept a stable patient. What the heck. Screw him. I chose to continue with my present management. I knew what to do anyway.

The patient was stable when I endorsed him to my reliever. Ultrasound was still pending, but all abdominal symptoms have disappeared. Before I left, I referred the patient to another surgeon, who was more amenable. When he saw the post thoracostomy xray, his words were "perfect placement". He looked at the patient's chart and commended my management. He then asked me if I was already done with general surgery residency, and if I was just moonlighting while waiting for the results of the exam administered by the board of surgery. i told him no, and he seemed surprised. He told me that I more capable than a lot of doctors who have already finished surgery residency. I couldn't help but smile. I was extremely pissed a few hours earlier, and all those miserable hours seemed to have vanished suddenly. It's great to end one's tour of duty on a high note. It makes the whole day seem fulfilling, even when it's not.

I understand why a lot of consultants don't really want to accept patients at the hospital where I'm working. For one thing, they are not adequately compensated. Most of these patients don't have money, and I guess they often get promisory notes as payment for all their efforts. i understand where they are coming from. Of course I want to receive just compensation as well. But these consultants are aware of this fact when they signed up. They are aware that it's a local government hospital, therefore majority of the patients that they would receive won't really have sufficient funds. If such patients would always be the least of their priorities, or worse--- if such patients won't even be a priority at all, they shouldn't have signed up in the first place.