Nowhere to go . . .

It was the festival of colors early this week. The whole country was in celebration. With our Prime Minister getting a major boost to his 'make India great again', the celebratory mood was well felt in every nook and corner of our communities. There were major things coming for the poor . . . the rich will be taken to task . . . there will be no more corruption . . . no-one will ever go hungry . . . there will be no more deprivation . . . there will be no more need for charity . . . 

I'm encouraged . . . I see a glimmer of hope for the marginalized and the poor in our communities. 

On the day of the Holi festivalI had just the sort of patient, who I feel should not exist in 2022, when the country celebrates it's 75th Independence Day. 

Mrs. A was not an unknown face. In fact, quite a many members of her family comes to us when there is a serious medical issue. In fact, it was just few weeks back that her nephew was brought to us with clinical meningitis and he made a miraculous recovery. I've known Mrs. A since the day we reached here. She was a known hypertensive and had been on irregular treatment. But, the last time we saw her was in October, when we diagnosed her to also have quite severe Ischaemic Heart Disease with some amount of cardiac failure and a bad pneumonia. 

As with the majority of our patients, she did not want to be taken to a higher centre. The maximum we could do to evaluate her was a Peripheral Smear and an ECG. Yes, not even an X-Ray. She made a miraculous recovery. 

But, she never returned for treatment. Alas, we also did not notice that she had not turned up for her regular medications. 

Her husband brought her in a miserable state sometime late morning last Monday (Holi). She was coughing with quite a lot of phlegm. Clinically, she got a bad pneumonia again which was causing quite a lot of stress on her badly damaged heart. I told the family that she needs evaluation. They told me that the maximum they could spare today was 500 INR. As usual they were not willing to take her ahead.

Over two days with some medicines to treat her lower respiratory infection and support her flailing heart, she made a miraculous recovery.

Reasons for her not coming for regular treatment for her high blood pressure and cardiac failure - they are very poor. There is one son who goes to work in the nearby town. He cannot go far as he has to look after his aged parents. There are couple of other sons who are earning a living in faraway places. They hardly come.

Now, it would be a great thing if such patients are taken care of. There are two ways to do it. The first is to ensure that the public health care system is robust.

And the other is to imagine that they don't exist. If the latter is the solution, people like me remain busy. 

Dilemma

Over the last fortnight, we had 3 elderly gentleman in various stages of some form of cardiac failure. The major issue was that they were quite painfully breathless. Couple of them had not slept for days.

The amazing thing about them was that all three of them did quite well following admission at NJH in the Acute Care Unit. Fowler beds, oxygen on continuous flow through a mask or nasal prong and a comfortable climate away from the heat . . . all of them played a good part in facilitating their recovery.

The issue was that I could not shift them out to the general wards leave alone think about sending them home. The oxygen, the comfortable bed and the temperature was the major issues giving them the short lived relief.

But, then I had a very pressing issue. Who was going to pay the costs involved in such a care? Oxygen on continuous flow, regular monitoring, mechanical ventilation for one of them. The relatives were already squabbling about the inheritance they would end up having once these elderly gentlemen passed away.

We had a serious problem with one of these them. The family was quite rich. But, none of the sons wanted to pay for the treatment of their father. Ultimately, we had to go into one long session of counselling and some amount of acting from my side.

They paid up, but took the gentleman home soon after. The same happened with the other 2 patients. The latter two realised that the acute care admission of the elders in the family would result in quite huge holes in their pockets.

I don’t blame them. In a setting where the resources are limited and there were other pressing needs in the family, a decision had to be taken.

Yesterday, I had a similar patient, this time, a lady. Her oxygen saturation was just 60% without oxygen. Very much in line with our experience with the 3 gentlemen, she also did quite well in acute care with all the support systems.

The options for the family of this lady was not much. They had agreed for admission as she had a RSBY Card. We could not keep her in acute care for more than 3 days.

For her Chronic Obstructive Lung Disease, the family could not even afford a spacer for their inhaler. Our staff fashioned out one with an empty intravenous drip bottle.

With advances in technology and availability of better medicines, even the poor have started to live longer. However, costs involved in chronic non-communicable disease care is quite a lot. The fact that there are better but costly treatment modalities for prolonging life as well as ensuring a better quality of life put many families into terrible guilt as they do not want to be seen as ignoring their loved ones.

Without a strong public health care system, the costs are going to be very high. Considering into fact that our public health care systems have not been able to respond to basic healthcare issues, I wonder how fast we would be able to deal with such situations of chronic disease care in the near future.

Till that happens, families would have to think twice before they take their elderly for treatment that does not do much more than just make them feel better and comfortable.

And for institutions such as ours, it involves taking ethical decisions for our patients. And it's not the first time that we've had to ponder over our decisions regarding managing such patients.