Thursday, April 12, 2007

Triage Tales 24

Disclaimer: The following story is a work of fiction. All similarities to people, places, things and events are coincidental by nature.

With all the talk of the First Gentleman Jose Miguel "Mike" Arroyo undergoing open heart surgery for a dissecting aortic aneurysm, I am reminded of a case we had that taught me something I will disclose later.

A 50-odd year old male comes to the ER complaining of severe chest pain radiating to the back. Luckily for us, the responsible companions bring their medical information with them. The abdominal ultrasound 5 months ago tell us he has the unfortunate luck of having an abdominal aortic aneurysm.

True enough, he had 40 pack-years of smoking and hypertension which was poorly controlled. Largely in part due to his stubbornness, he conveniently forgets his medication which could have stopped the progression of his aneurysm.

The patient is sedated, given morphine and calcium channel blockers to control the pain and bring down his blood pressure. After six hours the patient is seen by the thoracic and cardiovascular service and an ultrasound is done again, which shows an increase in the aneurysm from the initial 5cm to a whopping 8cm. Surgery is offered emergently, and the discussion with the patient and the responsible companions turn inevitably to cost considerations.

"Of course, the implants would be of a special kind (Gore-Tex, naturally), and the patient might have to be placed on a heart bypass machine, so we would be hard-pressed to do the surgery without buying the implants and renting a machine."

"How much would that cost?"

"The professional fees are waived of course, but we are looking for at least P150,000 for all the needed supplies for surgery."

The patient then declares, "I'm as fit as a horse," sits up, and tells the responsible companions "I want to go home."

After much protest from the ER Treatment Officer, explaining that the possibility for death is great, patient signs a Home Against Advice waiver. During all this, the surgical team musters a "We respect your decision" and takes their leave to inspect a nonhealing leg ulcer somewhere else in the hospital.

He is given oral antihypertensives and sent home with strict instructions to go back when the pain recurs.

20 hours later, a passenger jeep almost runs over some of the other bystanders milling around the entrance to the emergency room. The driver stops and three men carry what looks like an ashen middle-aged male to the resuscitation area. They look like they know their way around the ER, and they do; it's the patient with the "triple A".

No heart rate, BP 0. CPR is started, 2 large bore IVs are placed and fluids are given. It does not make a dent in the BP - only the tell tale sign of flank ecchymosis (bruising around the lower back) tells us that retroperitoneal hemorrhage has occurred. Grey-Turner sign told me that he bled out. Needless to say, he was gone.

The lesson I learned was that some of our countrymen have placed little emphasis on their health, that a condition like this was permitted to persist for 5 months. This turned a proposed elective procedure - the aneurysm repair - into an emergent one. Was it because the surgery was so expensive that it would be cheaper to pay for funeral costs? Or is it a sign of inadequate health care coverage for Filipinos that people had put off regular checkups for their own safety?

If everyone had responsible companions like that of Mike Arroyo, I would not worry about staying in this country. Because I would know then that health care is more of a priority than cell phones, or lottery tickets, or anything else. Then I would see less patients dying because they could not afford to have regular dialysis sessions. If the First Gentleman could afford continuous dialysis, I'm sure we could have saved some of those hazing victims because they too could have benefitted from early emergency dialysis.

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