e 3 a s h i g R E F L E C T I O N S

Life In Wild GP-Land

General practice (Family Medicine in UAE) is very much different from hospital medicine. You are out there in the wild far from the fenced castles of tests and investigations. You are on your own and there are no experts around you to ask for help. You have to depends on your own clinical judgment. Your personality and people skills are far more important than they are in hospital where common sense and compassion are sometimes lost in the midst of tests and paperwork. There is no where in medicine that you need to summon to the front the best of your personal qualities in dealing with people more than in GP-land. Patients you see can be confused, will not tell you what they really want and will sometimes hide their personal agendas from you. Forget about lab tests and XRAYs; they take forever and its likely your patient will either be dead or fully recovered by the time you get the results. There are also very difficult daily ethical dilemmas - life/death questions and decisions to be made where there is no absolute right or wrong. People will look up to you for guidance and help in making these decisions and often you find that the advise you are giving them have nothing to do with medicine. A compassionate friend or neighbour will have been able to give the same advise. You realise that your medical knowledge can only take you so far, for the rest of the way you need basic old common sense.

I spent few minutes checking my doctor’s bag and made sure I had a fresh pair of gloves, enough blood bottles, sterile needles, my stethoscope, a sphig for blood pressure and blank prescription sheets. I left the building and headed to a residential home where a lady was agitated and confused and was becoming disruptive to both residents and staff and needed to be looked at.

When I finished with her, I was asked if I don’t mind peeking at an other lady on my way out. She has been troubled with a sore throat for few days and has not been eating and drinking properly as a result. Of course, I didn’t mind for it would only take a minute. As soon I stepped into her room however, an erie feeling crept into my heart. A feeling I know all too well.

I introduced myself, took a short history and examined the lady. I then summoned all the authority I could master and said:

-”I think you should go to hospital”.

-”Hospital?”, she said in the most surprised tone. “I am not going anywhere. I feel fine!”

-”I don’t think you are fine, I think you are very poorly and need urgent fluids and medications to go straight into your veins. We can not do this here.”

It must have been a genuine surprise to her. She had only recently been discharged from hospital after a long admission but now she does have CAP with a CURB-65 score of 3 and I was certainly not going to treat her for that at home.

-”I know you have just been discharged and, to tell you the truth, I am not a big fan of hospitals myself. However, you need IV antibiotics and IV fluids and unfortunately, I can not give them to you here.”

-”You do what you can only love.”

-”You are not listening. I can not give you what you need here. I don’t have it. Only in hospital you could get it.”

I did not think she appreciated the seriousness of the situation. I wanted to say something definitive and clear. So I stood up and said:

-”You are going to deteriorate and then you could die if you do not go in today”

I paused to give her time to absorb it. Surely, no one wants a needless death - least of all I. An uncomfortable silence filled the room. A minute passed, then two, then three. I was determined not to break it. She appeared deep in thoughts, gazing at something invisible behind me while I stood quietly at the foot of her bed. I really wanted her to understand how serious the situation is. Her chances of survival with the resources available in the community are slim. Frail in her bed, she did not look much different than my own grandmother in the last few months of her life. She had thin broken skin that teared like the crust of pudding if you touched it and small calm eyes that lost their glow, the rim of their pupils blurred as it melts into the white. Her fine grey hair framed her small head. Her nose as sharp as the edge of a sword but her lips lost their thickness to the years of old age. Every thing about her was the way you expect it to be in an old lady of her age.

I am not sure how long have passed before she eventually looked at me and said:

-”No. I am not going back to hospital. I had a beautiful life. Please do what you can here but I am NOT going into hospital.”

There was little point of arguing. She already made up her mind. The staff at the residential home tried hopelessly to change her mind but it was clear to me that this lady is determined to stay where she is and to die where she is if she had to, rather than go to hospital.

I arranged for her to be treated where she is as best as I could with the available resources. I spoke to her family. They spoke to her and told me that this is what she wants. It was Friday when I saw her. When I came back on Monday, she was already gone. I went to sign her death certificate and saw her for the last time. She had a smile on her pale now motionless face. She did not look like she regretted anything. She was at peace.

PS:This post is dedicated to Ayman and the team working on a3mali. Sign up to their newsletter to hear when they unleesh their Beta website unto the people of Dubai.