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ramblings of an unknown psychiatrist

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Success Associated with Self is CAUSED: Failure Associated with Self is ONLY an Association

Posted by Dheeraj Kattula on June 6, 2009

He walked into the hospital with his sister and a friend, the other day. He had headache and fever for the past two weeks. His fever came and went at regular intervals. Everyone knew it could be malaria. Yes, it was. The blood tests showed he was positive for the malaria germ Plasmodium falciparum. His severe headache indicated this being the ominous cerebral (brain) malaria.

We gave him Injection Artesenuate, the nuke of anti-malarial arsenal. We also attacked the germs with other missiles Chloroquine, Sulphadiazine, Pyrimethamine. He should have improved in a day. He worsened. His fever disappeared but he was drowsy and had decreased activity.

We wanted to see if he had other germs affecting his brain. To test that we usually put a needle into a patient’s back ( lumbar puncture) and drain some fluid which bathes the brain. Before we do that we had to rule out increased pressure in his skull (Intra-Cranial Tension). If one does this procedure in a person with increased pressure in the skull, one could precipitate immediate death.

We had to dilate his pupils and look deep into his eyes. I found something different. The picture in both eyes was little different. It reminded me of a rare syndrome called Foster Kennedy Syndrome, which I had read about in 2001 and remembered only because of my penchant for rare syndromes. A wise medical goes like this- If you diagnose a rare disease you would be rarely correct. I still like to study what is rare because, if we do not study what is rare, it becomes rarer still.

We sought opinion of a good ophthalmologist. What we had written “ Left eye- ? Papilledema . Right eye – ? optic atrophy”, her findings were “ Left eye-?? Papilledema. Right eye -?? optic atrophy”. At least we were in right track. A CT scan of Brain needed to be done to confirm findings and ruling out a tumour in the brain. Fosner Kennedy Syndrome occurs in tumours of front part of the brain (frontal lobe).

We explained the relatives that the patient probably has a serious brain disease in addition to having malaria. The treatment for malaria was already on. The required CT scan of Brain could be done in the morning of next day. Till then we could not do anything. He was not well enough to be moved 250 km away where radiological, neurosurgical and expert medical services were available. They could not afford these either.

We gave the option of going to a Government Hospital at the District Head-Quarters (DHQH) where the CT could be done the next day. The relatives wanted to go the next day for investigation but wanted to continue treatment in our place. As the day progressed, his level of consciousness came down. At night the relatives asked us if we could guarantee that he would survive the night. We said that we could not guarantee that. Then they told us that they wanted to go to DHQH. We had to discharge him, knowing very well that nothing could be done there at such a time. The doctors there are over-worked and nursing department is understaffed to even deliver normal care.

Next day, in the evening my colleague and I decided visit him at DHQH. I wanted to check if our diagnosis was correct (a competence issue ) and he wanted to know if the patient is doing fine ( compassion issue ). After a search in various medical wards, we found a nurse and asked about him.

She said “Oh, that man, who was admitted in the Mission Hospital. He died today morning. We could not do anything. They referred him so late. What can we do? Many private hospitals refer patients who would die anyway, but they do not keep any patient till the last hour.”

She thought we were relatives, so she was thinking aloud. It was a blow to us. She felt we ‘did not know’ (competence)  and ‘we did not care’( compassion). We did not give any defense. She is not going to understand the medical issues. She had also made up her mind on our attitude. A single conversation is not going to change her views. So an apologia is a waste of time. We walked out slowly.

Saddened- for different reasons. My friend was sad as the patient who had walked in to the hospital died in two days, having worsened during treatment. I was sad that, after having picked a probable right rare diagnosis and having explained things to relatives they had reflected wrong views to others. Where had we gone wrong?

My friend said, “Patient was fine when he came in. He was started on treatment. The natural course of illness may have overtaken the treatments. They do not know that. His admission followed by his treatment is associated with his worsening condition. They would definitely attribute his death to treatment and not a hidden disease.”

We always enjoy the joy of patients’ improvement, attributing the cause to our treatments but we find it so difficult to digest when someone wrongly attributes bad outcomes to our treatment.

Isn’t it?


4 Responses to “Success Associated with Self is CAUSED: Failure Associated with Self is ONLY an Association”

  1. neerja said

    sure, because, we try to take responsibility of our actions and try to have some control in what goes on around us!! But, an experienced doctor might know that its better to have empathy towards patients rather than being emotionally involved.

    You are right in saying that. In our case we felt that we were doing the right thing and that we wanted the best interests of the patient.It so happened that in both issues of competence and empathy, we were mis-interpreted because of negative turn of events.

    It was a lesson for us to educate strongly about possible outcomes and chance of sudden worsening at anytime, which may not be treatment related.

    Thanks for reading the post and of course your comment 🙂

  2. That is one of the hazards of being a doctor I guess – being misunderstood, and motives being misinterpreted.. Nonetheless, what happened to that man is very sad.. If he was covered by insurance to go to the other hospital, would it have made a difference or was it already too late?

    PS: I didnt clearly get the meaning of the title.. Pray explain?

    • I am sorry. The title is indeed a bit complicated.Social Scientists are familiar with terms like ‘causation‘ and ‘association‘.

      Let me explain these with a story.
      During the second world war,German Air-Force bombed Britain black and blue.After the action was over relief teams began their operations in order to save the wounded and ones buried in the debris.
      On the third day relief workers found an old woman sitting in toilet of a ground floor house.They were surprised to find her alive.They were even more surprised that she was smiling !!! She softly told them, “You guys are not going to believe what I did”, she added “I pulled the flush and the whole building came down”.
      🙂 🙂

      Did you get the logic of causation and association?
      Air-Strikes were the cause.Her pulling the flush were an association.
      The funny thing is that she attributed ’cause’ of the fall of the building to her pulling of the flush,when it was merely ‘associated’ with a German plane dropping a bomb in their vicinity (actual cause).

      In this post I was saying that we are quick to claim credit for all that works well.If it is ‘associated’ with us, we might believe that we are the ’cause’. When things fail,we have a tendency to believe that we were just ‘associated’ and were not the ’cause’.

      The does not deal with the latter part.It shows that if the outcome is bad patients might see aggressive treatment as the ’cause’ for bad outcome and may not understand that aggressive treatment is supposed to be ‘associated’ with severe disease.

      I hope I have made some sense. At least this time… 🙂

    • Dheeraj Kattula said

      I forgot your main question.You asked “If he was covered by insurance to go to the other hospital, would it have made a difference or was it already too late?”

      The constraint here is not money.It was availability of facilities,time and nature of disease.
      If an urgent CT scan could be done,diagnosis would have been clear.
      Just because diagnosis is clear,it does not mean patient would do well.If he required neuro-surgery, it was available 250 km away.
      His condition was not stable to be shifted to that far.

      By the way,I have not seen any person with health insurance in my practice in Baripada for the past 15 months!! 🙂
      I do not have it either :-/

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