“Hello, Dr. Baticulon!”
I stood up from the cubicle where I was removing skin staples from the scalp of a patient, and saw that the jubilant voice came from a dark-skinned woman with deep-set eyes. She was standing at the doorway, just next to the nurse’s desk at the Neurosurgery outpatient clinic. When I looked to her direction, she waved her hand and gave me her biggest smile, such that I could see her molars even though she was three cubicles away.
Sino nga ‘to? I tried to pull out her name from memory and match it to the sound of her voice, but I couldn’t. She wore a plain white shirt, and to conceal her short hair, a ball cap with the name of a barangay councilor. The newly grown hair told me that she must have had major surgery recently. Staring at her as she approached, I realized that she was my patient from two months back. I was her resident-in-charge (“RIC”) when she was admitted in the hospital, but this was the first time I actually heard her say my name.
Until that moment, I never thought that she knew I was Dr. Baticulon. There was no way of knowing two months ago; the last time I saw her at the wards, she could not converse at all.
When Ofelia Reyes was brought to the emergency room in March for behavioral changes, the triage physician mistakenly directed her to Internal Medicine.
She was not speaking and nobody could give a reliable clinical history; originally from Davao, she was a factory worker who’d only been staying in Manila for the last two months. When the blank stares became increasingly frequent and she could no longer recognize people, it was a concerned co-worker who brought her to our hospital.
Her ER physician thought that her apathy, sparse verbal output, increase in sleeping time, and lack of interest in leisure activities were because of severe infection that has spread to her bloodstream. Either that, or she was showing neurologic symptoms of liver dysfunction. Upon admission at the wards however, the senior resident — incidentally, my classmate in med school — thought that something was amiss (e.g., questionable history of fever), so he requested for a cranial CT scan. The imaging study revealed a large mass at the frontal region of her brain. It did not look cancerous, but it was compressing the part of her brain that controls behavior and had significant brain swelling that could alter her wakefulness. She was then referred to the Neurosurgery service for possible excision of tumor and transfer of care.
When I came to examine Ofelia at the Medicine wards, she was drowsy, requiring persistent name-calling or tapping to keep her awake. She would only react to painful stimuli by saying “Aray!” and nothing more. She stared with delirious eyes. If you saw her wandering aimlessly, I would not fault you if you dismissed her as a homeless lunatic.
It was clear she needed surgery. However, our service faced a major problem: There was no one who could give legal consent for the operation.
Her co-worker and her co-worker’s husband took turns watching over Ofelia at the wards. They fed and dressed her. They facilitated laboratory workups. They procured medications from the hospital’s donor pharmacy. But they were showing signs of caregiver fatigue. When I explained the need for brain surgery, the co-worker’s husband was quick to reply:
“Dok, hindi ba pwedeng gamot na lang?”
They explained to me that they were afraid to be held accountable if she deteriorated or died from the operation, and rightly so. Being factory workers, they also did not have money to pay for the operating room needs. Both were hoping for a speedy recovery, so that they could go back to work and tend their children. Otherwise, they might just opt to bring Ofelia Reyes home against medical advice.
At our end, we have always been hesitant to do surgery when no one would take responsibility for the patient. No surgeon would give you a 100% success guarantee for any surgical procedure — every operation carries its own risks. Treatment does not end with the removal of the tumor, which may be technically easy. Full recovery is highly dependent on adequate post-operative care, which, in the case of neurosurgery patients, is usually provided by family members who spend long hours at the bedside. Caregivers are also primed regarding possible complications such as infection or post-operative bleeding, and they have to be prepared to spend for antibiotics or a second operation should the patient’s clinical course go awry.
For two days, the Internal Medicine and Neurosurgery services were in a gridlock. Internal Medicine could only give temporizing medications to keep her from slipping into coma. Our service had offered to provide operating room needs, but we still couldn’t do the operation without legal, surrogate consent. Worse, Ofelia had succumbed to hospital-acquired pneumonia during this time, not unlikely given her poor intake and weakened immune system. Her breathing had become too laborious, she had to be intubated and hooked to a mechanical ventilator.
It was intervention from the hospital’s social service unit that gave Ofelia a new lease in life. Social worker Mr. B approached me on the third day with a proposal.
“Dok Ronnie, kung tutulungan namin kayo sa gamit, kukuhaan namin siya ng dugo, at babantayan namin siya sa wards, ooperahan ba ninyo?”
My senior resident raised the issue of consent. Mr. B said that there’s a provision that allowed hospital administrative officials to sign the consent for cases of vagrants and abandoned patients like Ofelia; consent would not be a problem.
And thus, one Saturday morning, I made my way to the Medicine wards and pushed Ofelia’s stretcher bed and oxygen tank to the emergency operating room. To my exasperation, her watcher packed his bags and walked out, as if finally relieved of his duty.
Ofelia’s brain tumor was completely excised. In the days following her operation, she had to be admitted at the neurosurgical special care unit, but we were eventually able to wean her from the ventilator and transfer her to the ward. She had to stay in Bed 1, nearest the nurses and nursing aides who looked after her 24/7. The social service unit fulfilled its promise of providing medications, blood for transfusion, and other needs. No husband, son, or brother came to visit.
Initially, Ofelia had labile mood. During morning rounds, I would find her crying one moment, grinning the next. It took a couple of weeks before she began to interact with the people around her — smiling in gratitude for rationed food, signaling for water when thirsty, holding out her arms and legs when about to be dressed — akin to a child discovering the world for the first time.
There was one instance when I saw another patient’s watcher standing at her bedside and watching her eat breakfast. I jokingly asked Ofelia, “Boyfriend mo?” She blushed, and then shook her head left and right in protest.
My patient was making slow but definite progress.
Until one day, social worker Ms. R reported to me, “Dok Ronnie, sasamahan ko si Ofelia pauwi sa kanila bukas.”
“Ha, paano?” I said, knowing that my patient still could not carry a sensible conversation.
“Basta ituturo daw niya sa akin.”
True enough, the next morning when I did rounds, Bed 1 was empty.
Seeing her again at the Neurosurgery clinic two months later, I could not contain my excitement. Here’s a patient who almost died, but through selfless effort of public health workers, it’s as if nothing happened to her. A rebirth, almost.
“OK naman po, Dok!”
I immediately asked how she got home, and she told me the details of her trip with Ms. R, or at least the parts she remembered. She still had memory lapses from time to time, but otherwise she felt healthy. She expressed her gratitude to the doctors, nurses, nursing aides, interns, and social workers who took care of her. In a few days, she would go back to work. I asked if I could take her picture, and she smiled her biggest smile once more.
She was happiness personified, as I was.
I was her RIC, and she remembered my name.