INDEXING TITLE: RCHAN’S MAR [5-09]

TITLE:  Two Families in Contrast

PERIOD OF MEDICAL OBSERVATION: October, 2005

NARRATION:

         This medical anecdotal report is about two very different families I encountered recently… First is a tale of a mother’s dedication and love to her son:

         As I was coming out from the conference room, a weak woman’s voice called out to me…”Doktora!”  I turned towards the owner of the voice.  I readily recognized her face although now the lines of weariness and exhaustion were written all over it.  It seemed to me that she had at least aged 10 years more from the last time I saw her.  She was already in her 70’s, or so it seemed to me.  Her hunched, frail body inched towards me.  I instead walked towards her, being aware of the every ounce of energy she put from each step she took to come near me.

         She was the mother of my 31-year-old male rectosigmoid cancer patient. He underwent a transverse loop colostomy this July 2005 for complete intestinal obstruction.  Intraoperatively the staging was IIIB (T4N1M0).  The pelvis was frozen at the time and I had no choice but to exteriorize the transverse colon in the hopes that with chemoradiation therapy, resectability could later be achieved for definitive management.  During his recuperation, his mother nursed him to eventual recovery, patiently and lovingly attending to her son’s needs. We were able to discharge the patient after a week.

         Here she was again, gaining my admiration for her devotion to her disease-stricken son.  She had been approaching me for the past few days that week, inquiring for the next steps for the management of her son’s cancer.  I informed her of my plans of giving neoadjuvant chemoradiation therapy before we can attempt to resect the diseased colon.  She was quick to ask me how much everything would cost.  She confessed that her son was unable to work again because of his illness.  He had been completely dependent on her since then.  She was just a retired public school teacher, relying on the meager monthly pension she receives. She was going to seek financial assistance from the Philippine Charity Sweepstakes Office (PCSO). I gave her the clinical abstract, a copy of the record of operation and told her to have the histopath results photocopied and attached to the other requirements. I then computed for the chemotherapeutic dosages of her son’s regimen of 5-FU and Leucovorin for each cycle.  I instructed her to canvass around for cheaper brands of the said drugs and to come back thereafter so I can compute the total amount they would need.

         I expected her to come back a few days after that encounter that morning but lo and behold…that afternoon, there she was again at the ward, looking for me.  It was as if I was deceived by her seemingly fatigued riddled body earlier that day.  She did have a few more battery hours to spare after all…and it was all because of her unfathomable love for her son.

         She approached me with a faint smile on her lips, “Magandang tanghali po doktora. Pasensya na po inaabala ko na naman po kayo. Heto na po yung presyo ng mga gamot. (“Good afternoon Doctor. Please forgive me for bothering you again.  Here are the prices of the drugs.”)  I felt a pinch of sorrow in my heart as I became aware of how much sacrifices she had to make for her son.  I tried to imagine her walking in the busy streets of Manila going from drugstore to drugstore under the scorching heat of the afternoon sun with matching carbon monoxide from public utility vehicles weaving in and out of her bronchi, bronchioles and alveoli.  I told her that she should’ve done it on another day instead.  She was quick to reply however that her son was really insistent that he start the treatments right away so he can be operated on soon.

         I computed the cost for each cycle and handed her the estimated cost. Her hands shakingly received the paper I held out to her.  She stared at it for quite sometime. She looked up with tears rolling down her cheeks, “Naku malaki pala magagastos. Baka di nila sagutin lahat.” (“Oh no. It would cost a lot of money. They might not shoulder all the expenses.”)  I could only tell her that she just try it out first and if everything would be approved, she can start buying the drugs so I can make a schedule by then.  She thanked me and turned her back away from me. As I sized her up as she walked away, I noted she shrunk an inch or so…her shoulders dropped as she now carried the world on her shoulders…

         The second tale is as interesting as the first…

         A 59-year-old female patient was referred to us by the Department of Internal Medicine.  She had a one-year history of on-and-off abdominal pain. The pain increased in severity for the past two days.  She presented with an acute surgical abdomen on physical examination. Upright chest xray revealed pneumoperitoneum.  We entertained a perforated peptic ulcer since she had a history of peptic ulcer for two years already and was noncompliant to the treatment. She was accompanied by her niece and her older brother.  We informed the relatives of the urgency of performing surgery on their patient, to which they readily accepted.  We optimized the patient’s condition and prepared for the operation.

         Just as we were about to get a consent from her niece, she surprisingly declined.  Apparently, the patient was just taken into her care for the past four days. She was informed by the helper of the patient’s daughter, with whom the patient resides with, that the she had been having abdominal pain for the past few days.  There was no effort on her daughter’s part however, to bring her to the doctor for medical attention.  According to the helper, she just dismissed her mother’s complaints as, “nagpapapansin” and “nag-iinarte”. Noting the urgency of her aunt’s condition, she dropped by her cousin’s house and fetched the patient.  After two days of non-resolving and intensifying abdominal pain, she decided to bring the patient to OM.

         She informed her cousin of the patient’s condition on the phone, only to be scolded and reprimanded why she brought her to OM and not to St. Luke’s.  She was not allowed to sign for the consent for the operation. She was told to wait for her to come before they allow the doctors to operate on her mother.  She even threatened to sue the doctors who will open her up despite talking to one of the residents on the phone regarding her condition and the need for an urgent laparotomy.  She expressed her intentions of transferring her mother to St.Luke’s and have her surgery done there instead.  Our hands were tied and we were helpless. We had no choice but to concede to their demands.

         The patient’s daughter eventually arrived together with her brothers. Judging from the way they dressed themselves up, they looked as if they indeed can afford to pay for an admission and operation at St. Luke’s. After thorough explanation of her mother’s disease and the need for a stat operation, they finally gave the go signal.

         Intraoperatively, there was a perforated sigmoid colonic mass, most probably malignant 80% obstructing the lumen with generalized peritonitis and fecal soilage.  A Hartmann’s procedure was done.

         Post-operatively, we saw the relatives loitering around the surgery and the infirmary wards, checking out the rooms.  They approached us asking if they could be transferred to the pay ward.  We informed them that the patient would have to be re-classified as a pay patient.  They would then be charged professional fees from the consultant-in-charge and the anesthesiologist and they have to buy everything from then on.  They then inquired about the possibility of being relocated to Rooms 302 or 304. We explained to them that we only admit clean breast, thyroid, pay and Philhealth patients in those rooms. If they do not belong to the aforementioned, they are not eligible to be admitted there.  When asked if they still wanted their patient to be admitted as a pay patient, they shook their heads…this reaction from the very people who bragged about transferring their mother to St. Luke’s.

         The patient is now recuperating, not even being regularly visited by her children.  Attending to her needs is her daughter’s helper.  Beside her hospital bed stands a four-foot high suitcase, the heavy-duty and expensive kind (it was a Samsonite I think) you see that travelers lug around in airports. Packed inside it were all her clothes.  It was as if her daughter was sending her a message…go figure MOM!

INSIGHTS: (DISCOVERY, Stimulus, Reinforcement,physical, PSYCHOSOCIAL, ethical)

         Doctors and relatives should always work hand in hand in the management of their patients.  It’s a joint effort between them with one goal in mind…the hope for a cure for their patients.

         The first story shows an example of every doctor’s dream relative.  She was with us every step of the way.  We didn’t have a hard time explaining to her the disease and treatment of her son.  She understood the importance of giving chemotherapy, in spite of the cost and side effects. She was more than willing to exhaust all means necessary to support him and all the doctors treating him.  She was ready to make sacrifices for the life of her son. As the saying goes, “No parent should have to bury his/her child.” I’m sure that thought crossed her mind too. People like this mother drive us doctors to exert more effort in treating their patients.  For their commitment to their patient, they deserve nothing but the best of our services.

         The second story is the exact opposite…a doctor’s nightmare! It becomes so frustrating on our part whenever we encounter relatives who refuse to cooperate with the management plan of our patients. It may be due to financial constraints, of which we do not have any control of or because simply they do not care at all for the welfare of their patients.  The distressing part of it is that most of the relatives neglect their patients despite of them knowing that there is already something wrong with them.  They refuse to address to their complaints. They do not bring them to the hospital until they make a turn for the worst. They become complacent and pass all the responsibilities to the doctors in charge of their patient.  In our case, the patient was their very own mother, the woman who gave life to them. She risked her life to bring them into this world.  She nurtured them from their infancy to adulthood, providing them love and care.  And look at her now? Are these the same children she reared? Are these the same children she worked hard for and provided for to be sent to good schools and get an education?  Is this the way to treat your own flesh and blood?

        Relatives especially loved ones are essential in the recuperation of patients.  Their care and affection pushes their patients to recover faster. Tending to their needs sees their patients through their illnesses.  We as doctors can only heal these patients physically.  Their loved ones can heal them spiritually, mentally and emotionally. No medical studies, license or training required…and what can beat that?