cold

Side note: Yesterday on call, we ran out of alcohol swabs. Now, normally our 'swabs' are cotton balls that we dump a big bottle of 'methylated spirits' (ethanol/methanol) mix. We ran out of the methylated spirits, and so improvised by using normal (0.9%) saline solution. Ha! That's quite a bit more basic than not having a defibrillator.

In response to Joey's comment: There are diminishing marginal returns to healthcare (and pretty much everything else in life, or so economics 101 will teach you). What this means it that initial investments will reap the largest benefits in terms of reductions in mortality - basic hygiene, nutrition, sanitation, etc... reap the largest benefits in extending lifespan. This is why lifespan in developed countries has not changed that much since, say, the early 1900s - in spite of the fact that we spent hundreds of times more on healthcare now as compared to then. Inexpensive interventions - a clean well, toilets away from drinking water, good nutrition, HIV drugs in areas where the disease is pandemic - can thus go a long way in improving health outcomes. The more sophisticated stuff found in hospitals is nice, but compared to the basics, don't do nearly as much to extend life.

Ah - now back to the title of this blog entry...

As I wrote earlier, there are a lot of attempted suicides (called parasuicides) here. One of the doctors who has been working here for a while seems to be able to tell which are serious attempts and which are attempts at drawing attention. He laughts at / mocks / insults the latter group of people; indeed, many of the doctors here just say to their face that they are irresponsible and stupid for attempting suicide to draw attention. No apparent effort is made to deal with the mental health concerns that these patients might face. PCC (that's patient-centered care, a principle they rightly try to drill into you into med school that basically says that you must treat the patient as a whole and not just the disease) preceptors would be appalled.

Last night on call, we saw a few more parasuicides - the usual organophoshates, as well as methanol and indomethacin overdoses. I found myself joking with the interns on call that these people should just use morphine, since it just puts you to sleep and wouldn't seem to hurt as much as a failed ASA overdose. I did this while one of the parasuicide patients and her relatives were not more than a couple feet away from me (our ER is quite small). While it is true that these parasuicides are trying to draw attention to their plight, I can only assume that their plight must be sufficiently dire to ingest variouis painful, poisonous substances. I know this, and yet being in that environment, I said things that were heartless, insensitive and cold.

I have gone with one of the fellow doctors to 'certify' a couple of the patients. Certifying means doing an examination to confirm that the person is deceased. The first I saw certified was a boy - newly deceased so that if you looked at him, you would think he was okay except for the fact that there was no movement. The second and third, a middle-aged man and a middle-aged woman, with their families weeping around the bedside. I think those were the first times I saw people who were recently deceased. Maybe it was because I steeled myself before hand, but I can honestly say I didn't feel much emotionally. To the deaths of people in the prime of their lives and the grief of their relatives, I was cold.

In a setting like this, there is some sort of balance between feeling compassion and feeling nothing. When you feel nothing, you can be fast and effective. Your emotions won't overwhelm you when you see stuff that could be ameliorated if only the resources were available. On the other hand, the whole point is to be compassionate.