THE TWILIGHT ZONE EPISODE: THE QUALITY OF MERCY

THE TWILIGHT ZONE

There is a fifth dimension, beyond that which is known to man. It is a dimension as vast as space… and as timeless as infinity. It is the middle ground between light and shadow, between science and superstition… and it lies between the pit of man's fears and the summit of his knowledge. This is the dimension of imagination. It is an area which we call… the twilight zone.

EPISODE: THE QUALITY OF MERCY

It's April 2008, the grimy pages of a dirty, unkempt logbook of the emergency room. The place is the emergency room of the Cebu City Medical Centre. The medical personnel on staff are composed nurses and doctors who just started their shifts. Some started three hours ago and some just merely an hour. The head nurse approached an internal medicine resident doctor and informed him that a 38 year old female who was about 4 to 5 months pregnant had come in because she had an elevated blood pressure and already had two seizures in the obstetrics section in the emergency room where she was logged in according to protocol. The head nurse also informed the doctor it was unclear how far long the pregnancy was. The doctor then instructed the nurse to immediately call the obstetric resident in charge in the emergency room at the time to check the patient immediately. And as overworked and underpaid some of these people are, some whose dulled and tired eyes are set deep in dulled and tired faces can now look toward a miracle, that moment when this seeming nightmare appears to be coming to an end. But they've got one more battle to fight, and in a moment I’ll tell you of this nightmare on April 2008, Cebu City Medical Centre, Philippine Islands.

But as the facts unfold on that fateful day, it becomes apparent that in reality it is high noon in that dimension we normal people would call the Twilight Zone.

It’s 8:55 am, the head nurse approaches Dr. Abdul Badron, the IM resident on duty in the emergency room, and asks, “Doctor how many weeks equivalent in the age of gestation would a pregnant woman be if she has a fundal height of three finger breadths above the umbilicus?” “It would be about 20 weeks.” Dr. Badron replied. The nurse then told Dr. Badron that the patient already had two seizures while admitted in the ward. Dr. Badron told the nurse to immediately call the Obstetrics department to have a resident sent down immediately to examine the patient. “Doctor,” the nurse said, “we have already called them several times and they told us to have the patient examined by internal medicine because the LMP (last menstrual period) is unclear and that they will just co-manage it later.” Dr. Badron insisted that they have to send someone to check this patient immediately. He then received a phone call from Dr. Ennie Mainit the OB-GYN Chief Resident, requesting him to look at the patient first because according to her statement, “I know I cannot go down at that exact moment since I have a breech patient who is about to deliver any minute.” But according to Dr. Badron, Dr. Mainit called him up and insisted that he see the patient first because the LMP is not clear, and allegedly demanded, “What is the protocol there? The patient is 4 to 5 months!” “Just look her over,” Dr. Badron told Dr. Mainit over the phone, “If she is less than 20 weeks, I’ll accept the patient.” Then he just hung up the phone to avoid further arguments. According to Dr. Mainit, she called Dr. Badron again and asked him why he hung up on her and that she felt that it was very rude. Dr. Badron told her that he did not want any further arguments so he hung up. He told Dr. Mainit that he cannot admit the patient until she clears the patient of any obstetrical problem. Furious, Dr. Mainit, went down looking for Dr. Badron and according to her statement “I went to look down for Dr. Badron at the Emergency Room, not as a doctor anymore, but as a person who was angry at him for being rude to me.” Bear in mind that this was the doctor who couldn’t go down to see a pregnant woman with elevated blood pressure and who had already suffered two episodes of seizure. But now she was coming down in all her furious glory to confront the man who she found rude. But I digress…

So now here comes Dr. Mainit, furious for the alleged rudeness that was Dr. Badron hanging up the phone on her, to the emergency room looking for the errant doctor. Having found Dr. Badron, without asking about the pregnant patient which should have been her first concern, approached him and angrily said in a loud voice, “Bastos ka!...Bayot ka!” in front of all the patients, students, nurses and other staff in the emergency room. In the cebuano dialect, Dr. Mainit’s expletive meant, “You are rude! You are a fag!” Let us take a minute to compose ourselves from the shock that such esteemed members of our professional society is capable of such public display of undiscipline, rudeness and an utter lack of professional decorum.

Okay…minute over.

As this whole “teleserya” almost to the level of those we see on local television on primetime, and just as I got drawn in on who was rude, disrespectful and who was not, with all the how-dare-she and the theatrics that was going on for all the cebuano public to witness, what about the patient? You know those people doctors refer to when they swear “I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous.” Yes, that one. The 38 year old pregnant woman was still waiting in the emergency room. And yes, the petty name calling that the doctor resorted to is harmful and mischievous.

The 38 year old pregnant lady? She died later that afternoon. The woman delivered what doctors would call an “abortus” meaning a dead fetus and she eventually died. She reportedly died because of a brain haemorrhage as evidenced by the seizures and the elevated blood pressure that was already exhibited by 8:55am that morning. She leaves behind a husband and children.

Now in the hospital, the finger pointing has begun. That the reason for the death was not an obstetric one but an internal medicine one. WHO REALLY CARES? What amazes me is that they are still stuck on the fact on who should have looked at the patient first. Are these doctors morons? A patient is dead. A man is without a wife. Children are now without a mother. And they are debating if their behaviour was just? Every time I mull over the events, it gets me angrier and angrier and gets me frothing in the mouth. As I said, I am not a doctor. As the finger pointing between Obstetrics and Internal Medicine keep on, a non-medical person like me can’t help but ponder on these questions…..

Like, it was a Monday morning at 8:00, hospitals should have a full staff of residents on duty usually. Is it only one doctor in the OB department that can do a sign off as to whether a patient has an obstetric problem or not? I thought that the Emergency rooms should have a resident from each of the department. Why was their a resident from Internal Medicine only there and they had to call or find the OB resident? The OB ward by the way is on the second floor of the CCMC. Perhaps it must be tiring to go down one floor to see a patient. Dr. Mainit keeps on declaming that she was never rude to Dr. Badron and in fact, according to her statement, “My junior residents namely Dr. Aznar and Dr. Auguis can attest that I never said anything in a loud voice over the phone to Dr. Badron since they were beside me when I talked to him.” While I applaud her passion in declaring her non-culpability in the “debacle” or “drama”, it makes me wonder that if there were at least 3 OB residents in the OB ward that we know of, couldn’t she just have gone down and checked on the patient and have her two junior residents watch this alleged patient who was about to giver birth any minute that who was breeched? Now I am curious as to how many residents in the OB ward were there on that day and how many cases did they have that they had to baby sit and not leave for a few minutes to attend to an emergency.

Dr. Mainit in her statement again defends herself against Dr. Badron’s comment that instead of looking at the patient first , she chose to continue to argue with him, by saying that Dr. Aznar was with her and that she instructed to have Dr. Aznar check the patient. Question now is why did she not have Dr. Aznar check on the patient awhile ago instead of having Dr. Aznar just standing beside her while speaking to Dr. Badron on the phone?

If you go and check the Emergency Room of the other hospitals, be it private or public, there is always a resident doctor on duty for each department -- 1 from OB, 1 from Surgery, 1 from Internal Medicine, and 1 from Pediatrics. These resident doctors hardly ever leave their posts, and would only do so for meal breaks, bathroom breaks or endorsements and are usually gone for only less than an hour. And if they do have to leave their post that would be only the time they would allow a non-licensed Post-graduate Intern to cover. But apparently in CCMC, the exception seems to be the rule. And a perfect example would be the April 14 incident where they still had to call the OB department to send a head down. And what makes this more nauseating is that on that very morning, there were 10 OB residents on duty. And their Chief Resident could not spare one. For whatever the protocol is, the one qualified to go down to check on the pregnant lady in the emergency room while leaving the remaining 9 residents on duty to watch that patient who was supposedly to give birth any minute.

It makes me wonder if the unacceptable level of service and the amount of care these so called “doctors” give to these patients in a government hospital is because these patients are indigents, impoverished and have no money. Is it because a 30 peso urine test is even still unaffordable for these patients? That maybe these patients are not capable of ever returning favors that these doctors do for them? Is this the level of mercy our medical society can only afford to dispense? Do these doctors think themselves gods that it gives them the right to have such disregard for patients in this poverty level and utter disdain to those who they think is beneath their supposed station?

As I said, I am no saint. But then I also do not hold people’s lives in my hands. They chose their profession. And it is now apparent that not all of them chose it for the right reasons. There are stories abound in that hospital that make my hair stand. They range from the idiotic to the ludicrous and in instances like these deaths, to the tragic. There is a doctor who yelled at the vendors outside the hospital because the lowly vendor committed the capital crime of calling the doctor “Sir” instead of “Doctor”. He scolded them because he said “he is not a teacher or professor, he is a doctor who studied for 14 years!” There are stories of an employee being verbally abused wherein a doctor berates the receptionist in front of everyone else because she couldn’t quite clearly recognize who she was talking to on the phone and referred to the caller as “Sir” instead of “Doctor”. And so had the distinct pleasure of having the doctor come down from his office in Mount Olympus and ask the poor receptionist who was only on her second day and ask “Do you know who I am? Don’t you recognize my voice?” There is one about a senior resident who rudely called a patient “tiguang” all because the poor patient who was old made the mistake of calling him “dong”. There are allegations of doctors who literally cheat in their daily time records by indicating an 8:00am start time but when compared with biometric readouts, they arrived past 9am or 10am. When confronted with the discrepancy, the only punishment meted out was a slap on the wrist and were made to resubmit a “true” daily time record.

There are also rumors that some resident doctors are performing certain procedures and charging the patients professional fees for it claiming that the patients are being charged because it was the consultant who performed the procedure. But in reality, the consultants have no idea at all. In the Delivery Room, the OB residents are rumoured to shout at the patients for failing to “push” properly while delivering. There were even reports that a few of these OB doctors would slap the patients’ thighs if they do not “push” properly.

There are also allegations of chief resident doctors establishing tie-ups with drug companies where a department would prescribe only one brand for a certain period of time in exchange for cash. Allegedly these chief residents receive around P15,000-20,000 a month for such tie-up. This completely goes violates the generics law and worse, it takes advantage of the ignorance of the poor patients who know nothing better but to just to follow what their doctor says. I understand until there is actual proof, they will just be allegations. But then I do not see anything being done to at least discourage such practice or curtail such opportunities for fraud. There are no systems of controls or of even checks and balances. Any corporate entity would have these in place for good governance. And being a government institution, they should be at the forefront. These doctors who seem to forget that they are employees of the city, continue to perpetuate the impression that all government officials are corrupt and are more interested in lining their pockets than doing their jobs.

Because there so many impoverished areas in Cebu City and especially with the onslaught of the Dengue fever, I have yet to see the resident doctors of some departments attend a medical mission organized by CCMC or the city government to go to these areas or to address these specific issues. These doctors claim to be busy all the time, yet miraculously have their schedule free up should a convention in Manila come up especially when the expenses are footed by the city.

The horrific, ridiculous and petty nature of these stories almost takes the form of urban legends. It would have been laughable had it not been so tragic. And sadly without any proof, these stories will remain as they are – rumors. But then there is also the saying that where there is smoke, there is fire. If the hospital only had management that would actually start doing the jobs they were paid to do instead of scurrying around trying to keep their jobs without thought to actually what it is, maybe then we could actually see patients getting the care they so rightfully deserve without regard to race, creed, religion, and most important of all social standing.

For the pregnant lady who died later that day, could a few minutes of care administered earlier have helped? Instead of arguing and name calling, had they looked the patient over immediately, maybe a husband still have his wife. Maybe his children still have their mother. I have a feeling all Dr. Mainit will receive as a disciplinary action is a stern warning. A stern warning—that is the value of life they nonchalantly disregarded. Their prompt attention to a patient may or may not have helped. But we will never know now, will we? For al the posturing and blame these doctors are wont to do, I have always believed that a few minutes mattered. A few seconds could mean the difference of life and death. Awhile back, in the same hospital a patient died because of a medical technician read the blood type wrong. How that could happen is still totally beyond me. The sanction meted out? The medical technician was made to go on leave – with pay. Imagine that.

I am not a doctor. I am sure some may questions as to who I am to cast such judgment. But as I ponder on this story, perhaps common sense too and a heart should be part of a doctor’s make up. Hippocrates first law says:

“Medicine is of all the arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts. Their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medicine (and with it alone) except disgrace, and that does not hurt those who are familiar with it. Such persons are the figures which are introduced in tragedies, for as they have the shape, and dress, and personal appearance of an actor, but are not actors, so also physicians are many in title but very few in reality.”

How appropriate this law now seems and yet how non-existent is the nobility attributed to this profession is.

To the people who decide that all those who were derelict in their duty because they prioritized something trivial more than a patient’s life to just get a stern warning? They do not deserve the posts they occupy. Their nonchalance and their buddy-buddy attitudes encourage behaviour as abominable as this. Their tolerance aggravates the self-aggrandizement these doctors delude themselves with. What their cowardice continues to perpetuate is depraved indifference. In the U.S., that is a criminal offence punishable by imprisonment. How unfortunate we do not have that here.

As a medical society, as evidenced by this incident, and this is only one of many, and our reactions to it, shows what a disappointment we are. The patient should have been first. The patient deserves the care and mercy first above all else. Not the bloated egos of some of our doctors.

What happened on April 14 is like living in the Twilight Zone.

“The quality of mercy is not strained, it droppeth as the gentle rain from heaven upon the place beneath. It blesseth him that gives and him that takes.” This was from Shakespeare in The Merchant of Venice, but applicable to any moment in time, to any group of people, to any nation on the face of the Earth – or in this case, to the Twilight Zone.

Good Evening, my name is Rod Serling.