INDEXING TITLE: JPINGUL’S Medical Anecdotal Report [5-03]

TITLE: A Difficult Patient

PERIOD OF MEDICAL OBSERVATION: March 21, 2005

NARRATION:

Did you ever encounter a patient that did not want to obey, did not want to cooperate, did not want to listen, but demanded to be treated, by his/her own way?

My tour of duty was about to end, it was morning, my junior resident went upstairs for an errand, and the intern on duty woke me up to ask if we will insert an intravenous fluid and start mannitol on a patient involved in a vehicular accident. The intern added that the patient claimed that she was a resident doctor in a near by hospital.

I got up and examined the patient myself. As I approached, I noted that she had a hematoma on the right eye, extending to the right frontal area. She also had multiple abrasions on the left upper extremity. I introduced myself and asked her what department she was with.

On further examination, she had a GCS of 15, no motor or sensory deficit, and intact memory. As I was about to examine her abdomen for signs of peritoneal irritation, she exclaimed that there was nothing wrong with her abdomen and her concern was the hematoma and the headache she had.

I told her that I will start intravenous fluids, but will not give mannitol since I find no indication to give it. She said, "why not, I am already hypertensive." (which was 140/90) I stopped.

Then, I realized that she had no plan of being managed under my care. And she expressed her desire of being transferred to the hospital she was working in. I asked her to sign on the THOC (to hospital of choice) form, stating that by her decision, she removed all responsibility from our hospital.

I respected her decision. I did not let the intern insert the IVF, rather I inserted it myself with one shot. I ordered in a voice loud enough so that she can hear, "start mannitol 100 cc." After a few minutes, some of her co-residents came and she was eventually transferred by our ambulance.

After a week, I asked one of her co-residents, who was my classmate in high school, on how she was doing. She had an open elbow operation and a repair of the upper eye lid, and she was expected to return to work after 2 weeks.

INSIGHTS: (discovery, stimulus, REINFORCEMENT), (physical, PSYCHOSOCIAL, ETHICAL)

If I were in her place, I am presently a resident in Ospital ng Maynila, then I was taken to a small rural hospital, on self-examination, I noted I had peritoneal signs. I would have asked the doctor in that hospital to insert an IVF, then transfer me to OM, do away with the x-rays and the laboratories, with no time to loose, while I am still stable.

I would appear impolite and disrespectful. Would the doctor in that rural hospital understand? I might end up with no IVF at all, and finding my own transportation to Ospital ng Maynila. This is a typical scenario that I see from patients signing a transfer to hospital of choice. No IVF and no conduction.

For this patient, it was very atypical, even with a THOC, everything was provided. Though I did not know her, I found a relation to her, in providing service, being over-worked and underpaid. We were both learners and healers of the body, removing defects, repairing damages, and saving lives.

But, our lives can also be on the line. What happened to her could happen to anybody, even to me. As I facilitated the transfer for her, I was thinking that I was doing it for myself.