The pain of turning a patient away

At the Philippine General Hospital where I had my medical training, interns have the unique task of staffing the Triage post, that little table in the Emergency Room that stands between the healers and those in need of healing. Interns serve as frontliners to patients that flock to one of the largest hospitals in the Philippines. Young and clad in white, interns are the face of the hospital. To patients seeking treatment, interns are the face of hope.

Yet this hope is often hard to realize with limited financial and human resources. At PGH, resident doctors find themselves overwhelmed by too many patients, leaving little time for them to focus on each. The nurse-patient ratio is 1:20, a far cry from the ideal 1:4. With the dearth of staff to assist them, the companions—almost always family members—of patients who come to the emergency room even have to look for their own stretcher beds while others buy food and medicines. These companions, whom we call bantay, are bereft of sleeping space. During my internship I would see some of them spending the night on dismantled cardboard boxes under the patients’ beds. Truly, they are the unsung healthcare providers in public hospitals.

We—doctors, nurses and medical staff—take pride in the skills and resourcefulness we learn in this environment even as we, too, make sacrifices. Often, resident doctors shell out their own money to buy urgently-needed medicines. But even with our best intentions, given the limited space, facilities and staff, we could only admit a limited number of patients.

The French term “triage” literally means “to separate” or “to select.” And that’s essentially what is done at the Triage post: Patients are selected based on the severity of their illness and the availability of beds and personnel who can accommodate them. Once, I faced a US consul who would decide if I could go to the United States, and as I looked around the embassy waiting room filled with people who had pinned their hopes on a US visa, I felt there was too much power vested upon him. Some people might think that we, too, are playing god whenever we inform patients whether or not we can accommodate them. But do we really have the power to do what we want?

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Once, when I was at the Triage post, a young woman rushed to our table to say that her grandmother had a sudden weakness of the left side while they were having dinner. “Can you see her now?” the girl said. “It’s really an emergency!” I went to the ambulance to see the patient. Her face was uneven; she could move only her right hand and foot, and her blood pressure was 180/100. It was most likely a case of a stroke.

I proceeded to endorse the case to the resident doctor. But instead of immediately admitting the patient, as what should be done for patients suspected of having an acute stroke, the resident told me there was no chance the patient could be admitted: The stroke unit was full and there was much backlog, the CT scan was broken…

Instead, the resident gave me a referral form which the patient could fill out and bring to another hospital. I knew that without money or connections, they would have a very hard time finding a hospital that would admit them. Nonetheless, I had to tell the young woman: We’re sorry, we cannot admit your patient. But your patient requires urgent treatment, so I hope you can find a hospital immediately… I tried to explain the situation in a sincere, compassionate tone. But sympathy is not enough where healing is required.

“Anong klaseng doktor kayo?!” the young woman shouted, now speaking in Filipino to express her anguish and fury. She wanted to know what kind of doctors we were, and why we were doing nothing when her grandmother was dying. She vented all her emotions at me: grief, fear, anxiety—and now despair. She and her entire family had travelled to Manila all the way from Quezon, all in the name of hope! But I extinguished this hope.

I apologized, saying the hospital was really fully occupied. “Pasensya na po talaga, punong-puno na po talaga ang ospital,” I said, adding: “There are even backlogs… You can look at the waiting room to see for yourselves…”

A feeling of helplessness set in, and I was reminded of a lament uttered countless times by many other patients: “Palagi na lang kaming itinataboy. Saan pa kami pupunta?” Everywhere they went, they had been turned away. Where else could they go?

On the other hand, to admit this patient would be unfair to other patients who needed our care and attention. It was a catch-22 situation that I could not solve. Perhaps sympathy was the only gesture of goodwill I could provide, but could it ease the distress of this young woman, or relieve her grandmother of the effects of the stroke that was threatening her life?

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Helplessness in the face of such a system is one of the emotions we doctors had to suppress through time, in the same way that we have to meet death in the eye. Yet the desire to change things should not be lost among us.

If people knew how painful it is to turn away a patient, then they will realize this is a predicament, a sorrow, a shame that we all share. Only when healthcare is freely available to all, only when there are enough doctors and nurses in every hospital, only when a system is in place in which patients know where they can be cared for and provided treatment—that is the time when we can banish the shame and welcome each and every patient with words that mirror those of the Great Physician: “Come unto me, all of you who are weary and burdened… and I will give you rest!”

Gideon Lasco is a physician and medical anthropologist. Visit his website on health, culture and society at www.gideonlasco.com.