Why I Can't Seem To Leave Egypt's Health Industry

This is a reply to what was possibly the most depressing post I'd ever written here. To the friends and family that called me right after I had written that post and were possibly worried about my mental state, thank you. It was unnecessary but thank you. I'm going to try and write about the good things. The happy things. After all, the purpose of this blog was humor and not wanton depression. Anyways here goes.

I love the atmosphere at the hospital. I love that there's a united sentiment amidst all the doctors, workers, nurses and security staff. It's a sentiment of "We're all in this together. So let's try to do and make the best of it." I love the fact that if I have a problem with a patient, all I need to do is go and ask a fellow colleague on the same floor for his advice and we'll both work really hard to find a solution. Camraderie during wartimes.

I love meeting new people and their families. I love how for a while, I'm part of their life. I love how vastly different their life is to mine. I love that sometimes, when it's a good day, we share stories on the difficulties and glorious moments life seems to always throw our way. I love that for a moment, we're family.

I love it when it's late at night and one of the older patients can't sleep and so we sit up late at night just talking. I love asking them what their favourite subject is. I love when they say their favourite subject is English and so for the rest of their stay in the ward, I talk to them in English. I love the look their mother gives me when this happens.

I love when everything sometimes magically goes right for a critical patient and they come out of it 100 percent. I love that when they came in, they were distraught and torn with all these horrible emotions and when they left, all you can see on the patient and the patient's family is joy.

I love the chronic well managed patients. I love it everytime they're admitted again for a course of therapy and whatever underlying disease they have is managed well. I love catching up with them and their parents. I love how close our relationship has become.

I love that phone call I sometimes get from a parent months after a patient is discharged. I love hearing the boy or girl on the other line quarrel with her mother and say "Mom, give me the phone, I want to talk to the doctor now."

I love that sometimes in the ward, parents get to know other parents and offer support to one another. I love that when a patient is critical or not doing too well, all the other mothers pray for her and her child. I love how tearfelt this can actually be and how humbling it can be for me.

I love the silly romantic love affairs the younger patients sometimes have for each other. I love that I once had a male and female patient, both aged 10-11 and how they'd hold hands when they'd take their medication through the cannula because according to them, holding hands meant they'd have super powers and so they wouldn't feel the pain.

I love it when a parent asks me when their kid is discharged if they can have the follow ups at my clinic. I love the look on their faces when I tell them I'm far too young yet to have a clinic. I love how they tell me I'm going to be alright and how I'm going to be a great doctor when I get older. I love how red my face gets and how humbled I feel when I hear that.

I love it when a surgery goes by smoothly and the first time the parents meet their child after an operation, all I have to say are good things, happy things.

I love the mothers and fathers that take an active interest in their child's disease. I love having to explain, in broken Arabic what's going on. I love the laughs they sometimes get out of hearing my broken Arabic.

Most of all though, I love the stories. I believe in the power of stories, and I hope I continue to feel that way about them.

Good or bad, a story is a story, and sometimes that's enough. :)

Death

I know I've brought up death countless times, over the previous posts. I also know that I've talked about it at length with friends who wonder how, as doctors, we're able to deal with death so casually. I guess this is a post that'll help maybe clear up the misconceptions or at least give people an idea of how we deal or rather, process death in the health industry.

Bear in mind this is all going to be coming from an unclear mindset. No drafts and second drafts will be made, so there is a possibility I might veer off topic, and if I do that, then I apologize.

The first time we're exposed to death is in the morgue during our anatomy lessons. This happens in the first year, within the first week of education. I remember that clearly but not vividly. The class is usually divided up to 20 people to one corpse (specimen is always the preferred word) and we're shown muscles, nerves, arteries and veins. That first class is always interesting. You're always able to differentiate the students into two, those that will stay the course and those that finally realize they have no business being a doctor. You're able to differentiate through attitude. There are those that are unfazed, those that are interested, and those that just freak the fuck out. The professors explaining on the specimens are usually relentless in the fact that they will try to gross you out as much as possible. I've seen girls faint. I've seen boys puke. I remember thinking how cruel those professors were sometimes with the more queasy students. I probably didn't realize how necessary this 'reality slap' was until much later when I became an intern. I realized that they do it because they know for a fact, that if you can't stomach a preserved corpse, drained of all its blood, then there can possibly be no way for you to handle what will come later.

The specimens were drained of humanity. They were more like the preserved mummies you see at the museum than they were actually human beings. Still, that was probably my first time seeing a dead person in front of me.

Much later when you become an intern. That's when you truly witness death. There is a difference between seeing a dead body and seeing a person die before your eyes. I actually don't remember the first time I saw a person die. I do remember the first person I performed CPR on though. I don't particularly remember which round it was in, but I remember being ridiculously anxious over the arrest. The nurses had shouted out that there was an arrest and I ran to start performing CPR. I remember being very anxious and nervous. This was it. There was a chance that, through some maneuevers and medication, this patient might very well survive. It was ----exciting.  I also remember the nonchalant behavior of the residents. It was more a chore to them. They had this air of  "Oh, here we go again." rather than "I hope this patient survives." I was very upset by the demeanor. After all, why become a doctor at all, if that's the attitude that'll prevail.

In retrospect, I realized my naivete.

I remember asking my senior resident about it. All he told me was

"You'll understand later."

He was right. I did understand later.

Arrests aren't portrayed very well on television. On TV shows, when someone arrests, there's a chance they come back at 100 percent ; that all that's necessary is bringing back that base line to a normal heart rhythm and suddenly everything will be okay again. That's a very rare thing. It might be true in trauma cases and sudden arrests but usually when a patient arrests in the hospital, it's because his or her body is giving out. Sure, you can do CPR and give them some adrenaline and they'll come back, but that only means that most likely, they're going to arrest again within a few hours. We call these patients Post Arrest patients. When you're looking for an ICU spot for these patients because obviously when they come back they need to be ventilated mechanically (something you don't see in the TV shows either) the resident in charge of the ICU will very rarely ever admit them. That's because they're hopeless. It's a harsh reality, but it's also the truth. When you're in charge of an ICU, selecting a hopeful patient over a hopeless patient is always the priority. The question usually asked is "Will his stay in the ICU actually improve his condition or just be a place for him to die in?"

It's a difficult question. It's also totally lost on patients' families.After all, they'd just been told that his heart stopped and now it's back. As far as they're concerned, there's still hope.

I hate false hope. I understand the need for it. Doesn't mean I still can't hate it.

I remember the first death that mattered though. That didn't happen until I became a resident. It was during my second or third month and I was on call in the ward. There was a kid, who had something called Fallot's Tetralogy (which was a congenital heart disease). It's not the worst cardiac disease a kid can have here, and there's a surgery that can correct it completely (given that they fulfill the criteria for it). This kid however, did not fulfill the criteria for the surgery (her brain was damaged, which was a complication for neglected Fallot patients and so her brain was basically mush which meant that even doing the surgery wouldn't bring her back to 100 percent). I remember always sitting down with the mother trying to explain to her, in the nicest way possible, that there was no hope.

That sucked.

Anyways, the kid had arrested during a shift and so, I nonchalantly started doing all the necessary things we do when a patient arrests. It didn't work. She didn't come back. The mother was out buying diapers so she came a few minutes right after we called the time of death. I remember telling her. She wore the niqab, so all I could see were her sad watery eyes. She was angry. She was angry that she wasn't around. She was angry with me. She was angry with the surgeons. She was angry at God.  She kept shouting that she should have been there. I told her there was nothing she could do. She told me it wasn't about that. She said,

"I just wish I could have spent those final minutes with her."

Yeah.

I say this story because during the CPR and during the arrest, I felt nothing. There was no empathy. If anything, I was glad. This was by all means a hopeless patient and it was time for her to no longer be in pain.

That all changes when you see the reactions of the parents.

I'd mentioned in a previous post that that's why I hated the good parents. That is why I hate them. That empathy you feel, it doesn't help in making you a better doctor. It's just a burden that comes with the job.


I think the issue is how routine it gets to be, and that's exactly the thing. Death, to alot of people, is something that's witnessed in the most trying of times. It's an event. But for us, it's no longer this catastrophic event. It's just something that happens that we deal with.

I think I hate that it's no longer this event though. I remember once I was sitting with friends (not doctors) and I had a shift the next day. I remember calling up the doctor who was on call that day and asking him how the ICU was.

"So how's the ICU?"
"It's alright, Patient A is dying though so good luck delivering the news to the parents tomorrow."
"Oh man, is there no way she's going to die with you tonight?"
"Doubt it. But tomorrow definitely."
"God damnit. Fine, but I hope she dies with you."

My friends were flabbergasted. All they could think about was how harsh and cruel I seemed to be. It didn't help that we were both laughing about it as we were talking about it. Keep in mind, I'm censoring how cruel these conversations can be. Jokes are usually made about how the on call doctor should just kill the patient now and things like that.

It is cruel.

But only if you're not a doctor, and it's not because we have the notion of being superior to non doctors.

It's because we have to cope.

Otherwise, we'd all just kill ourselves.

Why I Can No Longer Stand Egypt's Health Industry.

I hate that a lot of the patients I see are dying or on the verge of death. I hate that parents aren't educated or well informed enough to notice catastrophic symptoms and signs in their kids. I hate that usually, it's too late by the time they come to the hospital.

I hate that sometimes, a patient will come in, and there won't be place to admit them. I hate the way I feel every single time I tell the parents of a sick kid to go on a wild goose chase looking for an incubator or an ICU bed. I hate how hopeless I feel, and how hopeful they feel when I tell them.

I hate it when a kid dies, and I know something could have been done to prevent his or her death. I hate having to tell the parents, "It's all part of God's plan."

I hate seeing fathers treat their wives and kids like shit when it's visiting hours. I hate having to hear fathers go on about how it's time for the mother to come back home because he can't handle the house. I especially hate hearing the phrase "You said he was going to die anyways right? Well, we might as well go back home and care for our other children." I hate it because sometimes, it's a true and real thing.

I hate that sometimes surgeries are rushed or delayed not depending on the patient's health but more so on the whims of the surgeon. I hate that the bureaucracy can sometimes be so maddening, that all that's left for a distressed parent, is to cry in a corridor making sure his wife doesn't see him.

I hate the good parents. The parents that are supportive, understanding and completely and genuinely polite. I hate giving them bad news. I hate them for letting me sympathize with them so badly.

I hate having to see parents lie to the older kids. Telling them they're going to be okay when it's clear they're not going to be. I hate the false hope instilled sometimes, in the child's bright and fleeting eyes.

I hate seeing a mother give birth to her 8th baby. I hate having been part of her bringing this baby to the world, who will most likely grow up impoverished and resentful.

I hate the way the system works. I hate how it jades you and hardens your heart. I hate that I no longer treat death with the same respect it eternally deserves.

I hate the older professors, most of them having abandoned the public teaching hospital that taught them so much, all in search of greener pastures. I hate that the system forced them to resort to thinking like that.

I hate walking down the street adjacent to my hospital. I hate having to accidentally bump into a parent I haven't seen in ages and having them tell me how their son or daughter died a month or two after they left the ward due to some chronic illness they were having. I hate the looks they sometimes give me, with good reason.

I guess what I hate the most is how helpless I sometimes feel when I go back home, lie down in bed and close my eyes.

The Public Sector vs The Private Sector (Or How I Grew Up To Be a Dickhead Doctor)

Okay, I'm about to go on a rant and ignore the fact that I haven't posted here for over a year so bear with me here.

Now you all know how much I bitch about the public health system here in Egypt. It's a mess. Facilities are minimal and the load is heavy, but despite that I like to think that sometimes we do good work. It's not the BEST work, but at least I can go home and sleep at night without having any ghosts of dead children wallowing and wailing over my sleepy carcass.

I've recently started to work in the private sector, specifically a post operative ICU. That means I work in an ICU that receives kids that just had major surgeries and it's my job to manage their recovery and make sure they, you know, don't die.

I had all these thoughts about how much better the private sector was going to be. After all, why wouldn't it? Better equipment, better facilities and better yet, there should be a lesser load (as in number of patients)

I was wrong. I was horribly wrong.

I mentioned previously how being a doctor, you sort of have to kill off the part of you that really sympathizes with patients, not all of it mind you, but just a little bit so you're able to function without any preconceived emotions clouding your judgement. Working in the private sector, I've realized that you have to kill off ALL of it.

Let me explain why using my favorite method of analysis: bullet points!

• In the public sector, the problem is always that there's no money and too many patients. So what happens in post operative ICUs is that there is a limit to two things, the number of patients you can have in the ICU, and the number of surgeries you can have in one day. The first one is self explanatory. If there are 20 beds with 20 ventilators, you can't have 21 patients. The second point means that there's only a finite number of surgeries a day because the surgeon working in the public sector isn't getting paid shit. That means that after he's done with his surgery he'll have to go work in the private sector to make his money. It has its cons for sure, for example there's a never ending list of patients, but that can also be a good thing.
  
  For example, say a child has chest infection or a fever and he was scheduled for surgery today. In the public sector, that child's surgery gets rescheduled and another patient ends up getting the surgery. When the sick child eventually gets better, he'll have the operation. It doesn't matter for the surgeon because he knows he's going to work 2 cases a day. It doesn't matter which cases he works so long as he works them.
  
  Now let's imagine this scenario in the private sector. Let's say a child has a surgery scheduled for today but he's got a chest infection. FUCK THAT SHIT, let's cut him open anyways. Why? Because there's a finite number of patients and the surgeon gets paid handsomely for each surgery. He has incentive to perform the surgery, fuck all consequences because at the end of the day, he's going back home with a big fat stinking check devoid of humanity. Now let's say we have 4 beds left but there are 6 operations scheduled for today. In the public sector, the ICU is closed until the beds get empty again, whether through death or recovery. Not true in the private sector. Something called 'overbedding' happens where there are more patients than there are beds. I do not need to explain what this means because obviously, you can understand how horrible a situation like this is. Why doesn't one of the surgeons cancel his surgery you might ask? Well, why would Surgeon A cancel his surgery when Surgeon B is working his and gets paid? Fuck that shit, I'm going to do the operation myself and we'll see what happens. After all, I get paid for the surgery, not for the welfare of the child afterwards.
  
  This game I call "Penis Envy Surgery Chicken" needs to stop. It doesn't though. Because like I said, money.

• This one is going to suck ass at explaining but here we go. Okay, so let's say the kid had his surgery and complications happened, whether in the ICU or during the operation itself. In the public sector, we cut no corners in explaining how bad the prognosis of the kid is. Sometimes, doctors are extra harsh in dealing out this information. If the parents dare complain or put the blame on someone, they are constantly reminded that the operation was a costly endeavor and that they should thank God that their kid was at least given the chance of a life free of any problems, even if it didn't pan out so well.
  
  The way doctors look at their work in the public sector, it's sort of like a 'charity'. I'm not getting paid for shit and you already signed away any legal rights you might have had with our iron clad 'pre-surgery' contract. Sorry your kid's going to die madame, but those are the ropes, EVEN if the surgeon or the ICU doctor (intensivist) made a huge mistake. You aren't worried about consequences because as far as you're concerned, no legal action will ever be taken so there's no need to pad out the horrible news.
  
  Now the private sector, that's different. The patient is 'entitled'. He's paid money to have the surgery. He gets his say in what's happening. So what do the doctors do? We pad the truth so much it becomes a downright lie. Things like "Oh he's got some secretions in his lung but he'll respond to the antibiotics we hope" are said instead of "Well, he's got pneumonia and we're not sure the antibiotics are working." Why do we lie? Because the truth means more questions. "Why did he get pneumonia?" "Why is hygiene piss poor?" "What do you mean the operation didn't work out as planned?" The more questions asked, the more likely it'll be evident that somewhere down the line, something could have happened to prevent the child from deteriorating.
  
  So we lie, and my God does it takes its toll on the soul. 

• But at least we've got the facilities in the private sector right? Right? Also not true. In the public sector, we are funded through two mechanisms: Government money and donations by people. Most of the money goes directly into providing whatever facilities because money is scarce and because no one, thankfully from what I've seen so far, is going to steal from donations (which is where most of the supplies and medication comes from) Now who funds in the private sector? Hospital managers and owners. People. Not institutions. And they're trying to make as much buck as they can. So corners are once again cut. Why buy new ventilators when we've got perfectly ancient but functioning ventilators. Monitors aren't working? Come on, do you REALLY need to monitor a patient's fucking vitals? I'm exaggerating a little bit but that's the truth. All the hospital managers care about is getting by with the least amount of money invested into the hospital so that they can make a fatter profit. Paychecks are sometimes delayed or handed out in increments. Nurses are especially fucked in this scenario (at least in the hospital I work in). 

Okay, so 3 massive bullet points, but you get my point. All this, gives the doctors a sense of superiority and grandiosity that feeds their ego and turns them into dickheads. In summary:

You are getting paid handsomely, for half-assing medical care, with no worry whatsoever of any legal or ethical (because that dies out early on) consequences.

Fuck.


PS: Obviously, I'm focusing on the horrible here. At the end of the day, the private sector does ensure a better survival rate but there are different reasons for that which I'll one day explain in a different post that'll have a somewhat brighter view.