The Elephant and the Blind Men

4 Jul

“It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it”
– Sir William Osle

That was quite a busy day for me. While working as a –fulltime senior consulting general surgeon , in a public charitable trust hospital, which happens to be a premier neurological institute in central part of my country, we have a daily outpatient department. In the morning I was busy operating on a emergency abdominal problem. Around 12 noon I came down rushing to OPD as I had another emergency to handle again. Quickly I called upon – Asharani 25 years old female who came from 300 kms distance. As soon as I saw her – a young, fair, sickly woman holding her neck stiff, I asked her to narrate what is wrong with her .She showed me a big 8cmX7cmX6cm size cystic swelling on her manubrium sternum. It was painless when it appeared 6 months back & now it has become painful for one month, it was fluctuant. I had in mind “ a cold abscess” diagnosis. When I asked her about stiff neck, she told me that she is sick for 6-8 months and the neck stiffness is there for about 40-45 days. I asked her to open her mouth and put torchlight there. Hey!! My expectation was correct. There was a big retropharangeal swelling on the right side protruding anteriorly in pharynx. Now my diagnosis got almost confirmed. When I touched her upper cervical spine she was uncomfortable. Stiffness of her neck with stretched stermomastoid on right side was an aftermath of Pott’s cervical spine I could guess. I had to confirm my diagnosis by some necessary investigations. I advised her for X-ray chest, X ray neck AP & Lateral views haemogram, IgG and IgM for TB Elisa, and ultimately CT Scan of cervical spine.

I was in a hurry to go back to OT for the next surgery. I told her to show me all the reports when I came back from the operation. And when I was back the diagnosis was confirmed beyond doubt.

When I asked her why she came so late? The following story was narrated by her relative as –
“Doctor, for last 6 months we have been consulting specialists in a big district place. We took all the medicines sincerely, but she continued to feel ill. We changed the doctors, specialists. She was given cervical traction and physiotherapy so many days, she had received a couple of injections, but there is no relief. We are disgusted with everybody there so came here. Tell us what is wrong with her? No doctor has told us what is wrong with her .

When I saw her previous papers I also got disgusted. She had been practically taken to six senior consultants of different specialities. Amongst them 2 were orthopedic surgeons, 2 general physicians and 2 general surgeons too. None of them had even tried to diagnose her ,instead she had received a list of variety of medicines, injections, traction and physiotherapy etc ,without a Diagnosis.

Her CT Scan was showing evidence of lysis in C2 body, base of odontoid &right lateral mass of C2& right foramen transversum with large paravertebral collection[abscess] with early A-A dislocation [A-A distance-4 mm.] Bilateral minimal epidural collection ,carotid vessels pushed laterally on right side. She was balancing her head on a very thin rim of cortex of her C2 spine; which could have easily given way and she could have became Quadriplegic !!!!,
Similar lytic area in Manubrium sternum with large extra thoracic &smaller intrathoracic collection[abscess] was also reported.
Her IgG for TB was 2600 serounits (strongly positive) .
A young woman with two small children from a country where no doctor can afford to forget about the diagnosis of Tuberculosis and can manage to use all the sophisticated investigations on earth, easily available and also affordable for this particular patient, has progressed to the hilt of quadriplegia. Thanks to her neck stiffness – a protective phenomenon of her body, her inability to swallow properly, else this thin rim could have given way. It would have caused collapse & quadriplegia . Is there any difference at all in a young woman without quadriplegia and a young woman with quadriplegia? I reffered the patient to our hospital’s Neurosurgeon, we got her admitted. Next day her cold abscess from both places was evacuated and posterior fixation of cervical spine was done. She was put on full 5 drug AKT [ Anti kochs Treatment ] regime and a Philadelfia Collar was given . Gradually she got completely alright. We told the relatives how narrowly she is escaped from quadriplegia. They were extremely grateful to us. She went home on 14th postoperative day walking.

But I am terribly disturbed from this incidence!! I presented this patient’s case along with my questions to our doctor colleagues:
1. Do we expect patients to choose their specialists? And tell their diagnosis to them so that they can start treatment ?
2. Do we expect our colleagues not to give medicines to anybody unless they make a diagnosis ?
3. Are these people to be called qualified & expert quacks, though they’re having masters degree in their specialty they don’t take strains for diagnosis and treat the patients? Don’t exert, as these patients are illiterate?
4. Can they justify – their behavior stating a saying – “eyes don’t see what the mind doesn’t know !”
5. Stating that when they saw the patient –
1. It was an early stage of the disease, so they could miss the diagnosis.
2. Or they have a very busy OPD and couldn’t devote much time to take proper history and examination. And when I saw and diagnosed it was a “fully blown”? Case, so very easy to diagnose.

Indeed it was very easy to diagnose for me because I always want to diagnose and then treat my patients. As 5 days before I saw, a physician MD medicine had seen the patient and had labeled her as some cyst??? And referred to me for a surgical opinion !!
6. To blame their tubular vision and forget or blame patient’s relatives.
7. Patient might not have followed a single doctor so how can the doctor know patient’s progress? When she is lost to follow-up. Indeed this patient has changed 6 specialists in 8 months but why?
8. Here I remember an old story of 6 blind men and an elephant. Each one tried to feel the elephant. Whatever part they felt they labeled it as they thought. One who touched the tail said it’s a rope, other feeling leg, said it as tree, one feeling & holding trunk mistook it as a- big tube, one felt Tusks as sword, other holding big ear thought it as leaf and the 6th felt the body , thought it’s a wall. Entire elephant cannot be felt easily and so inability to judge . But blind men had never seen an elephant so they cannot be blamed .

Here these are educated, supposed to have acquired knowledge & having all 5 special+1 common senses and a license to treat. They forgot important principle – that ‘THE PATIENTS ARE OURSELVES’. This one grave incidence tells so many things about the society. Very often we see many, undiagnosed or misdiagnosed but treated (How and for what) patients. Medical knowledge has reached the level of telemedicine and telesurgery is coming in. But there is so much disparity in availability of treatment. There are many social, political, educational and financial reasons.

The fundamental aim of medical art and science has always been to alleviate human pain and suffering. Have we really achieved it? So giving only symptomatic treatment often masks the internal disease & allows it to progress ,creates complications ,increases morbidity & may even kill the patient.

“If it is a question of doubt in diagnosis you may often observe that one man solves the doubt when the others could not, and the way in which one man happened to solve it is this: he applied to the diagnosis of the case some method of examination which the others had not applied” – (Lockwood)

General practice, speciality , subspeciality or superspeciality whatever any doctor may practice the crux of curing any patient lies in two most important aspects of treatment i.e. : 1.Timely diagnosis
2. Timely treatment
We don’t need hi tech machinery or big hospitals to at least suspect the Diagnosis & the cure follows .

As long as any doctor physician/surgeon knows the importance of these two utmost important things patients will not get justice by way of cure, they may become more morbid or die ultimately. I am not pointing towards terminally sick cancer patients or massive myocardial infraction patients whom we fail to save in spite of following the above two norms. I am bringing forth the patient who can surely be saved if and when they get timely diagnosis and timely treatment. In this era of modern sophisticated medical practice so many times we find that The Physician may play the part of a pathogen; it may be by commission or omission . The possibilities & dangers of commission in short can be listed as —–
A- Iatrogenic Diseases….assaults of Modern therapy, injuditious use of therapeutic agents ,thoughtlessly , needlessly & indescriminately given blood transfusions ,exposure to diagnostic & therapeutic ionising radiation. Antibiotics are regarded as the cure for all for the most minor infections & steroid therapy is the refuge of the destitute, it is small wonder that the old maladies are replaced by new manmade ones, multitude of allergens exceeds pathogenic microorganisms in number. The degree of benefit to the patient is not by any means directly proportional to the number of procedures, tests & drugs used.

B—The threat of omission is represented by failure of the doctor to understand patients as people rather than as cases of abnormal physiology & biochemistry. Doctor has to learn to see & treat the person , not the disease .
I compare this tendency of doctors (not to let go any patient without writing a prescription ) with the priests of a temple , where no devotee goes without taking the holy water (teertha). Do they feel scared of refering to other proper specialist ,so that they lose monetorily . Medicine claims the patient even when the etiology is uncertain , prognosis unfavourable , & the therapy of an experimental nature . Under these circumstances the attempt at a medical miracle can be a hedge against failure, since miracles amy only be hoped for & cannot by definition be expected . The radical monopoly over health care that the contemporary physician claims now forces him to reassume priestly & royal functions that his ancestors gave up when they became specialized as technical healers .
The ritualization of crisis , a general trait of a morbid society ,does three things for the doctor. It provides him With a license that usually only the military can claim . The professional who is believed to be in command can easily presume immunity from the ordinary rules of justice & decency. So many doctors are so busy in practice that they have very little time to ‘listen’ to a patient’s complaint ,no time to thorougly make a good physical examination , so a short cut is adapted . Only chief complaints are heard (not listened) & an array of investigations are written for the patient .So many want their pathologists & radiologists to give them a diagnosis . We were taught in the Medical collages to give prime importance to patient’s history , & good physical examination , corelating these to come to a provisional diagnosis & differential diagnosis. To confirm the diagnosis help of investigations is taken & a Final diagnosis is made , before starting the treatment. To follow 7 stages of ‘diagnostic crescendo’.
Tubular vision –every specialist seeing his or her system or part of the system , forgetting that human body is not a machine of assembled spare parts. Man is more than the sum total of his organs & parts.

 
Ivan Illich has already concluded Doctor’s effectiveness in patients’ cure as an illusion . But in all cases it’s not true. Efforts are needed to educate our population so that they can help in their own diagnosis , can know that only high technology & lot’s of money can not save them in critical problems . They must demand their diagnosis from their doctors, should ask questions to their physician & then only take treatment. This Medicine’s Forgotten Man should make his presence felt in every stage of his diagnosis & treatment .

 

About the Author

Author: Dr. Sanjeevanee Kelkar

About: A general surgeon & for last 16 yrs working as a full time General Surgeon in a Charitable Trust Hospital in Nagpur.She is also a Senior Consultant & Medical Superintendent also for last 5 years.

Contact: http://www.drsanjeevanee.com
sanjeevanee@yahoo.com

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