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Last week, a 76 year old lady, admitted in a comatose state, after being unconscious at home for three days, and after a miraculous recovery to her previous mildly demented state, checked out, against medical advice. She had spent ten days in the ICU, without external support, for the simple reason that she was septic, and the blood pressure would swing wildly and dangerously. That continued, even when she was awake and interacting. The reason of discharge was that the family was running low on funds. The department, where the son worked, from then on, would have supported only three-fourths of the bills. She smiled as I waved her goodbye wondering with guilt that in all probability, she would pass away in her sleep the next night, when the blood pressure would touch 'zero' again. Treatable, but treatment, was not to be continued.
Close to the end of the year, on information, and by a call of conscience, I drove to another hospital to see a dear friend, who had a severe headache in the morning and was conscious for the next five hours, but due to some confusion, he was admitted by the family under cardiac care as he had undergone an angioplasty ten years ago. The CT scan head, done by afternoon showed a bleed. A couple of hours later, he lapsed into coma, and was on ventilatory support. That was a good hospital, but for reasons not known to me, the family had not pressed for the services of a neurologist. There was reluctance, but I knew, much damage had been done, and a personal will to get a team together was the need. I could shift him by the first hour past midnight. Mortality in such cases is somewhat directly related to the amount of bleed, but he was conscious five hours after admission and had actually re-bled later. Odds were against, but one does not leave a young man, with most reflexes intact, undiagnosed, and without the best effort. The point of bleed (that had now stopped) was detected by afternoon that day, and we were ready with an interventional procedure. Midway, before the point of leak (aneurysm) could be plugged, the blood culture report showed infection, and being a definite contraindication, the procedure postponed. Anyway, the benefits of the procedure were to prevent the next bleed, and he had to survive this one.
Over the next five days, the brain continued to sink, and so did his other reflexes. He was not sustaining the assaults of the hemorrhage, and intervening to prevent the next one became riskier and of no immediate benefit. The case was open and I called some senior professors, and they concurred. Close to the end of the first week of Jan, he gradually slipped away, forever. He was a dear friend. That was a different sense of loss. There was no question of my charging anything, but during those unending days, his wife and her brothers, close friend's all, never came to discuss the case, even to squeeze out a faint hope or a white lie from me. I haven't heard from them as yet, including the doctor who informed me of the mishap. Money, I know was not a problem.
It is becoming commoner than we think that the really sick and yet fortunate may succumb, not because of lack of care or funds or a blundering doctor, but because those left to take decisions get too confused because of the lives they have been leading. These are really the middle classes known to live by their sweat and morals. In the second case, for eight hours, the family had not even pressed for the services of a neurologist, or decided to shift to another setup.
It is true that good medicine is scarce, and in spite of our comparatively low tariffs, still unaffordable for many. But denial of reasoned, transparent state of the art care, when bills are affordable and the team well known, opens up another dimension of the competent and upwardly mobile Indian middle class.
So, is it the stress or is it that our cosmetic affluence leaves little for such mishaps. Is widespread medical insurance the crucial missing player in terms of presence and performance that the government should immediately look into? Could it be that vague budget-less ambitions to create 'assets' -- the final and crucial way to financial security, that allows no letup even at the cost of fading human bonds? How reliable and true are the ones who take such decisions, and what contribution - professional or material - can one expect for the society from those who changed colors when one of their own blood perished?
Signs are that the great Indian middle class is cracking, or does it need some financial reprieve to mend? I am amazed I have ended up talking of the budget!
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Comments:
Sort by: Oldest | Newest | Recommended (19) | Most DiscussedFebruary 04,2010 at 12:47 PM IST
Laypersons don't really know which kind of doctor is to be called...a neuro in this case, or a cardiac. Was the family told a neuro might be the right person to be consulted? I don't see why they wouldn't have consulted one, if told to do so.
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(Reply to VG)-
February 05,2010 at 12:16 PM IST
I really do not know why. Please do not take any personal case, for such is not my intention. At a personal level I may be held as a bigger defaulter. This is just a caveat. The fact however is that the real stats of drunken driving, or ruthless escapades are not with the police, for there the arguments are tuned for purposes of defence in law. The incrimation rate is also pretty less. At the repair shop, and the denting station, some other facts come to notice, because now the insurance company,to avoid payment or part payment, for reasons right or wrong, comes up with other facts as the actual coverage of the policy, need for proper licencing, whether there the vehicle was properly maintained etc. and these are valid too as a part of the contract. In fact, the insurance company is not empowered to decide who's fault it is for purposes of payment, which is just the opposite of the objective of recording evidence before the police. Here, is the situation to decide whether payments shall be made or not. That is where the coin drops. Please be with me. It is only a trend that i have noticed with my subjective sensing. I shall put myself first. We are looking at human concerns in our society. You may not know, but many are the times when i have to repeat, 'Thou art a better man than I....',before those I think I look after. I thank you for your remarks. Now, lets work for some sops in this budget to take care of our health bills.
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February 04,2010 at 01:08 PM IST
Dear Sir,
The times are changing but in a harsh manner.The middle class of our society is the biggest sufferer of these changing times. It fights with itself on two fonts, firstly to maintain the values and secondly to earn sufficient money to keep pace with the modernity. Unfortunately it fails on both the front! In a rat race to earn money it losses the values and when values are lost instances like the one mentioned in your write up take place. Unluckily more and more such incidents will take place in future as we head towards more and more of materialistic life. NAA KOI BHABHI NAA KOI BHAIYA SABSE BADA RUPIYA
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February 04,2010 at 01:09 PM IST
Hello, Dr. Kohli! Nice piece of article. I truly endorse the idea of an insurance cover for all. In my opinion the lower middle class is lacking funds while the upper middle class is lacking decision making. Treating patients of trauma and cardiac emergencies would become easier once the patient has an insurance.
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February 04,2010 at 01:35 PM IST
even in countries who have medical insurance have other problems in the insurances , they have to wait for long time to be attended by the doctor in spite being covered by insurance in developed countries . no system in such is full proof .
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February 04,2010 at 01:36 PM IST
even in countries who have medical insurance have other problems in the insurances , they have to wait for long time to be attended by the doctor in spite being covered by insurance in developed countries . no system in such is full proof .
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February 04,2010 at 09:01 PM IST
Dear Dr. Kohli
Is not it that, once the patient is admitted in a Hospital and that too such a big Hospital,it is the duty of Medical Personnels to diagnose and treat without even asking the relatives. Because how much these relatives know, what the sickness is.?They are as good as illiterates.
YOU KNOW BETTER, OF COURSE.
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(Reply to Ashok Gupta)-
February 05,2010 at 12:39 PM IST
Sure, i agree that the system should be transparent enough to allow the family to give, withold, or even deny treatment. They also have a right at all times during the course of a treatment to take a second, third, or fourth opinion. They certainly should also exercise and ask for full tranparency. It is indeed a proverb that a patient anywhere in the world, is a complete or a partial illiterate as to his illness. I stress that patients should exercise their full right to know what is going on. They must verify and convince themselves. Medicine is very much service for payment in the private sector. Doctors, once under contract, cannot deny a satisfactory explanation. Patients should also not deprive themselves of the right to information. That is how the system runs, and it is that enlightened society that we want to live in.
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February 04,2010 at 10:55 PM IST
in andhrapradesh every whitecard holder or BPL holder is given free treatment in all corporate hospitals,if any intracranial bleed ,immediately agiowasdone and anyerysm if present is clipped and all is free in corporate hospital,and why don't thee indian governemnt or other states start similiar insurance programme like arogyasri started by dr ys rajashekarreddy,in andhra the poor people are looked after in corporate hospitals like sheiks and everthing is online
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February 05,2010 at 09:13 AM IST
Truly agree with your thoughts Dr Kholi.But what internally goes inside the close boundry of ICU is really very difficult to figure out. There needs to be transperancy in the procedure and its the doctor's responsibilty to tell the family what is best of the patient instead of hospital.
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February 05,2010 at 11:56 AM IST
Dr Kohli, I know what it means when the dearest person is ill. I faced the same situation some months back when I took my dad for angioplasty in apollo. I trusted them and they converted a normal person to something else which I do not even want to remember. My dad is a doctor, a retired proffessor.being so much educated also our family was cheated so much. Loss of money is not a problem but I am glad that after shifting from apollo my dad recovered from everything.
Being a doctor's daughter I know the pain doctors bear. But I never can pardon apollo kolkata for their negligence.
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(Reply to Archita )-
February 14,2010 at 03:33 PM IST
Madam
Now my friend struggling for his life. First in Yashoda next in Appolo and now in care. What is the remedy for this medical criminality
with regards
govind
social worker
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February 05,2010 at 05:25 PM IST
I full agree with the views expressed by the writer. I feel the middle class is the biggest sufferer as they are sandwich between the two classes and also simplicity of life has been replaced by the modernity,materialism, consumerism and above all brand'ism.
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February 06,2010 at 12:10 AM IST
India is a large country and we need public healthcare system. But the system has failed. The american system will prove to be a most expensive bet in India. Anyway, the point of the article is something else... It is dwindling morals & values. People have started giving up. Like in case of the 76 yr old - She is old enough to die is an attitude carried by many these days. That is what is causing all these. Its not just money, but willingness to spend. Plus lack of awareness, in case of the second patient. How can the relatives suggest neuro. The doctors should say lets call the neuro, it is not a cardiac problem.
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February 06,2010 at 01:57 AM IST
The middle clsss in most societies are left in the middle. The are not poor enough or rich enough. The problem is that many governments ignore the middle class. This is the class that suffers the most.
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February 06,2010 at 11:26 AM IST
Dr Kohli, you are a trained professional and therefore able to take decisions for loved ones' care. Also, you have access to a wide spectrum of medical opinions outside your field. Let's not assume that the average citizen (whether rich or poor, educated or not, insured or otherwise) has similar advantages or, more importantly, can understand what's going on. He/She may also lack the confidence to take a decision that could result in tragedy. It's quite common-place in such instances to let God decide. Doctors, by virtue of their life-saving skills, are often held in almost as high reverance as God. If the patient (your friend)'s family didn't approach you for information or consultation, what prevented you from going to them to share medical info and advise them of their options? Surely, no one can accuse you of solicitation or undue influence! The final decision taken may be the patient's and/or family's, but responsibility to empower them to make an informed choice, and be aware of options, lies with the doctors. After that, it's not within your professional ambit to question their motives for taking a decision, unless you suspect some criminal intent. My condolences for your loss (of a friend).
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February 08,2010 at 10:56 AM IST
Hi Anup:
After reading a few articles like yours, I have developed a liking for you bloggers.
Sadly, I ran away from Bharat some 35 years ago; sorry, now I can't live there any more, even in New Delhi. Culture shock in reverse? Yes. I find it extremely funny.
Could you please tell me, despite the great thinkers I admire, why India is a place the way it is: public squalor, to put it politely.
I respect your opinion.
Best wishes,
Dilip
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February 09,2010 at 12:44 PM IST
Like the dalai lama, my commitment to peace and spiritual growth is total.Live and let live.May everyone live in peace and flourish.God Bless.
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February 10,2010 at 03:23 AM IST
This is not a story I would have expected! I've known many Indian physicians and surgeons and they did not lack diagnostic or decision making ability. I cannot understand why Dr. Kohli's friend did not have an Interventional Radiologist and/or Neurosurgeon immediately upon diagnosis. That is a medical decision that the family is informed of rather than something the family has to ask for. ??
Mr. Mukerjee, India is a fine, vigorous, and aggressive country - not a place of public squalor. She has burdens and challenges but she also has people who can shoulder the burdens and overcome the challenges. I believe India is about to come into her own in the near future.
Just the opinion of an old American woman who spent a bit of time in New Delhi when I was young (1970's). I was deeply impressed by the vigor, generosity, and kindness of India's people. Go-getters one and all!
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