‘Doctor Sahib I have a patient known to me ,who needs your consultation. He has no cardiac problem but has been asked to get clearance before hernia surgery,’ asked one acquaintance at the hospital gate.
“Get him on Wednesday to OPD, I will see him there.
Make sure you come with ECG done to save time,” I replied.
It is Wednesday , I saw my last patient in OPD at around 4:30 pm who was an elderly man planned for Cataract surgery without any apparent cardiac issues but as per protocol (to be defined?) to give a procedural safety warranty certificate of ‘No contraindication to Surgery!’
Exhausted brain with foggy and cloudy neuronal templates, I made my way towards the canteen for rejuvenating my dried up neuronal chips.
On my way , someone called from behind with a familiar voice, I looked back and found the same person whom I had asked a day before to bring along a patient with ECG to clear for surgery which he had been insisting on.
Invariably, the last patient would have been one who got an appointment by haggling with a security personal /attending gate staff member who would have come and announced that ‘I would meet the doctor and go, come what may’ types. Both often turn out to be suffering from major trouble. But being a hospital employee he knew tricks of trade and got the patient towards the end.
Over the years, the ‘last patients’ (in hospital OPD) have had much more medical problems like heart attacks, cardiac arrhythmias or evolving stroke; where the patient believed that he has gas, dyspepsia or a vertigo. In my cardiac residency , we used to call it ‘last token syndrome’.
Seeing this patient with my exhausted and torn out neurons , I peeped into the rusty polythene bag to look for the previous records …encrypted lifelines -ECG strips- on which I got hands on and found he had previously also advanced conduction tissue disease but ironically put on beta blockers and digoxin only to knock down his rhythm still lower…
The fresh ECG revealed complete heart block with escape ventricular rhythm @ of just over 30bpm …I asked the patient for any symptoms of unresponsiveness (syncope/presyncope)…to which he replied he gets lapses of loss of contact with surroundings for fraction of seconds in which he sees his deceased wife’s mirage flashing in front of his twittering eyes.
Alarmingly ,I counseled the patient for an emergent referral to an advanced cardiac centre for pacing. Patients attendants were still not aware of the catastrophe but just insisting on clearance for elective non obstructive inguinal hernia repair.
Irony is that the attendant was a hospital employee !
After 20 minutes of painstaking counselling motivated the patient and relatives for referral and am happy to know that the patient has been put on Temporary pacemaker and planned for permanent pacing now.
How can we avoid this problem?
Why not straight to the Emergency Room(ER)?
The answer is not so simple. It is not the patients fault.
In our system, the doctor is always given an iconic stature; while the system is neglected. There are many excellent doctors but they have to work in a rusted system…
In contrast, in the US and other developed countries ,the system is very strong. In a strong system an average doctor does well, while the reverse is not true.
In our system one might wrongly diagnose an atypical chest pain as muscular and miss out on a heart attack. In advanced set up , all such pains would mandatorily have an ECG done. If the ECG shows a heart attack, and unfortunately you are in a rural hospital, you have to be content with some aspirin and wait for the next bus to take you to the nearest town, while in the advanced set up , the system will make sure that you are taken to a higher center in a helicopter.
It is this lack of belief in a system that brings this ‘last patient’ to the OPD.
‘Don’t do anything without consulting me’
The patient, overwhelmed by the weight of my degrees would just do that, unless I tell him that in an emergency don’t wait for me and go to the ER. That can happen if the doctor can ensure that the hospital ER is a strong system, capable of responding to a crisis.
Mostly it doesn’t.
The ‘last patient’ has just obeyed his doctor’s advice.
The ‘Over’ Reaction
Just before COVID struck ,I saw a last patient coming in with a huge plaster in his hand.
Time 4-30 pm
‘Doctor, I was waiting for 2 hours to see you’
He sat down.
‘See Mr, I am a cardiologist. This is clearly an ortho problem. Why don’t you go to the right doctor? I am sorry but I am helpless’
He listened to me quietly.
After my long lecture ended, he looked at me, and smiled.
‘My wife is your patient. I just came to ask if she can have a dental extraction’.
‘And this is an accident that happened a month back, I am fine and active now’
As I told you, the last patient always springs a surprise. Didn’t I?
Dr Showkat Hussain Shah is Consultant Cardiologist at GMC Anantnag
Disclaimer: The views and opinions expressed in this article are the personal opinions of the author. The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.