Iran Standard Time | Desolation Day: 24 Hours in the Life of an ER Doctor
by ASHFIA HASANI
04 May 2012 23:17
[ dispatch ] Sickness and morbidity are conditions so universal that finding elements about them that are unique to Iran is difficult. Still, working as a doctor, especially an ER physician, gives one the rare opportunity to observe a society at its best and its worst. You encounter the neglected, forgotten, and wronged, and yet, perhaps even simultaneously, you bear witness to acts of heroism, love, and affection. By telling the story of one of my days working as an ER physician in an urban hospital in Iran, I hope that I can provide you with a glimpse inside the struggles and challenges of modern Iranian society.
ER service is hard and stressful anywhere in the world. But being underpaid and overworked doesn't help. As a GP, I am paid $600 a month, while I work sometimes as many as 100 hours in a week. My situation is not unique; almost all GPs in Iran are grossly underpaid. The ER where I work, despite several rounds of repairs and refits, still looks battered and run down. The exhausted staff tend to greet patients unenthusiastically and with a touch of aggression. It seems that the ER manages to suck the liveliness out of everyone who works there for any length of time. Although I try my best to greet everyone with a broad smile, by the end of my 24-hour shifts I can barely muster a mere fasciculation of the lips.
These problems plague most ERs in the country; all public hospitals suffer from lack of resources, old infrastructure, underpaid and overworked staff. The private hospitals fare much better, but the main burden of health care is borne by the public facilities. The private hospitals largely limit themselves to performing elective procedures -- mostly cosmetic surgery -- and even though they are required to have an ER, it is routine for them to unlawfully refuse to admit critical patients.
My most unforgettable shift was a bitter cold day in February. By then I had worked in the ER for two months and had adapted to the routine. The day started relatively well, with some ordinary sorts of cases: a man with influenza, a child with diarrhea, and an asthmatic whose condition was aggravated by the thick smog of the city.
Iranians put great stock in antibiotics, especially parenteral antibiotics -- the man with influenza demanded a shot of penicillin, which I refused. I hopelessly tried to explain that he had a viral condition which would not respond to antibiotic treatment, but still he left grumbling and cursing under his breath. I prescribed ORT (oral rehydration therapy) for the child, again struggling to explain to the parents that their child did not need antibiotics or an IV infusion. The father was not having any of it. He yelled at his wife, "Let's go to a real doctor who knows what he's doing."
Sure enough, they took the child with them without even considering ORT. I knew that they would go to a private clinic where a doctor would cater to their every wish as long as they were willing to pay, which would almost certainly mean that the child would receive unnecessary and quite possibly harmful treatment. The only mildly satisfied patient was the asthmatic man, who responded well to treatment but still managed to find something wrong with the speed of service and give me a good ten minutes of verbal abuse when I revisited him on my rounds.
All morning, patients with minor complaints kept coming in; one after another, I had to deal with runny noses and grumbling guts. The problem with our ER, as well as with many others in the country, is that we have no triage system in place. The hospital cannot afford to hire a triage nurse and so everyone who comes in is guided to my office. Unfortunately, Iranians seem to have no understanding of what words such as "emergency" and "urgency" actually mean. In our ER, which is in a rather dodgy part of the city, it is not even first come, first served; whoever is most aggressive or can yell loudest is shown into my office first. I have given up trying to explain that a common cold is not an emergency and just hope that those patients truly in need of care are not overlooked amid the unending stream of patients with minor complaints.
At noon, just as I was starting my lunch (which I have to eat right there in the ER, as there is no one else to cover the floor), one of those serious cases was brought in. It was a man in his 20s, who in the heat of an argument with his family had swallowed a bottle cap full of the herbicide Paraquat. As yet, he was complaining only of burning in his mouth. I administered charcoal and performed a urine sodium dithionate test that proved he was poisoned. Then I had to give them the bad news: the highly fatal poison was in his blood and he needed to be transferred immediately to a center with hemodialysis equipment. The boy and his family were devastated. Given his still minor symptoms, they could not believe how serious the situation was. When I found out that the whole thing had been over a $30 phone bill, I was devastated in turn: a life for 30 dollars.
Every day, I see many attempted suicides. Most of them are not serious cases, but there are exceptions. Most are young adults -- typically a girl whose family has found out about a secret relationship she has with a boy. Having a boyfriend or a girlfriend is still a big taboo in Iran, especially in rural areas and conservative cities. Along with financial woes, it is one of the leading causes of family conflict and consequently suicide attempts. Fortunately, most just take a bunch of pills to ease the family pressure or gain the attention of their loved ones. But during almost every one of my shifts, I face a more serious case. While most are saved, due to lack of follow-up and the persistence of the root causes, many of these young people try again and again until they succeed.
The fate of the boy had caused me great anguish, but before I could regain my composure the EMS staff brought in two bloody bodies and I jumped to look at them: a child and her mother. They were victims of a car crash on the main road nearby; their Iranian-made Kia Pride had collided with a truck, instantly killing two members of their family. Road accidents are a major source of injury and mortality in Iran, and thus a sizable share of my patient load are crash victims -- at my particular location, mainly motorcyclists. I stabilized the mother, who was more critical, as best as I could, called the attending surgeon, and with his consent prepped her for immediate surgery.
Fortunately, the child was stable and unharmed except for a few cuts and bruises. As I was inspecting her, a young man with an insignificant cut on his arm came toward me, yelling. He grabbed my lab coat and threatened to beat me up because he had been in the ER for five minutes already and had not been seen to. I tried to break free, but he was much bigger and stronger. Suddenly, a seemingly frail elderly lady rushed to my aid and to my surprise managed to extricate me. She took me to a corner and sat me down, then started to speak calmly to the young man. By the time security showed up, it all was over. (The security personnel always arrive suspiciously late to such altercations, leaving the medical staff vulnerable to the displays of violence that regularly erupt in the ER.) Fighting back tears and anger, I told the young man that I would tend to him immediately after I finished inspecting the child. She, visibly suffering from physical pain as well as grief at the tragedy that had just befallen her family, took my hand and said, "Khubid aghaye, doctor?" Her compassion in the face of what she was enduring made my day. Are you OK, doctor?
To be honest, I don't blame anyone for being edgy. Life is quite hard for most people around here, but despite widespread poverty, many still manage to be amicable and kind most of the time. If you are a foreigner here visiting, I can assure you that even in the poorest corner you will find many welcoming souls and even many who will share their little food or battered shelter with you. Even the young man came to me a few minutes later, ashamed. He apologized, kissed me on the cheeks (as is customary in Iran), and tried to explain why he had lashed out. I interrupted him with a simple "It's OK," and he nodded. We Iranians hardly ever hold a grudge.
My shift was turning out to be a hectic scenario fit for an episode of ER, and it was only to get worse. A woman in her 70s complaining of hip pain was brought in by her daughter. Suspecting a hip fracture, I ordered an X-ray. Sure enough, she had a femoral neck fracture that would require an arthroplasty. When I told her this and described the potential cost of the surgery, she and her daughter burst into tears and wanted to leave. The cost of health care has spiraled up in recent years, which means that every major medical intervention imposes a catastrophic burden on the average household, let alone poor ones.
Seeing their desperation, I called the supervisor and with her permission filled out a form requesting special presidential aid for the woman. Ahmadinejad has set up a petition system to help impoverished citizens with serious problems: patients are referred to the local ostandari (governor's office), where they receive a presidential letter that requires public hospitals to provide them service free of charge. The doctors in such cases also give considerable discounts or even waive their fees altogether because their cooperation puts them in good standing with the authorities; most of the patients are thus referred to well-connected doctors who want to remain in the official loop. This system has been fairly effective, though it has contributed to the public hospitals' growing level of debt. I hospitalized the mother and told the daughter to take the form to the ostandari the next day. Fortunately, our attending orthopedist needs a lot of official favors!
By eight in the evening, the ER had become overcrowded and it was proving to be too much. I called the supervisor and told her that we could not handle any more patients and that she needed to tell the ambulance dispatchers to direct any further cases in the area to another hospital. For the most part, they complied. From then until the next morning, EMS brought in only two patients; one with chest pain that proved to be nothing serious; the other, a boy of 12 who was a regular at the ER. His name was Sina. An HIV-positive street child addicted to IV heroin, he was usually brought in suffering either from withdrawal or an overdose.
Because of his HIV status, both the juvenile detention center and the behzisti (state welfare organization) refused to keep him for long. This time Sina had overdosed after injecting a mixture of heroin and lemon juice. He responded to Naloxone and I told the nurse to call the social worker, but he fled from the hospital the instant he regained consciousness. Unfortunately, what we can do is limited; the healthcare system is not supported by a functioning social welfare system capable of following up on cases such as Sina's. We thus encounter such patients at successive stages of their ceaseless downward spiral, until one last visit after which we never see them again.
I had previously tried to help such patients and I had tried very hard to help Sina in particular, but I had failed miserably, and every time I saw him I was struck by the extent of that failure: my own failure as a doctor, the hospital's failure, the healthcare system's failure, the society's failure, our collective failure as human beings.
Later a drunken man was brought in by police. While drinking alcohol, like taking drugs, is criminalized in Iran, the authorities prefer not to prosecute most drunks or addicts and they are taken to hospitals instead. (Drunkenness is punishable by 80 lashes under the law, but only rarely is a drunk taken to jail to face this punishment.) While I appreciate the tolerance, there is nothing we can do for them. So I just provided the drunken man with a bed so he could sleep it off.
The tragedy of the shift came at 3 a.m. By then, all was calm and I was snoozing behind my desk when I was woken up by the desperate plea of a chador-clad woman: "Bring him to life." She put a 15-day-old infant swaddled in many layers of clothing and fabric on my desk. I unwrapped the child and looked: cyanosed and mottled, he was dead. He had been dead for at least half an hour. I put on my stethoscope and searched for a heart sound. There was none. I started CPR and with the first chest compression I saw a frothy fluid coming out of his mouth. I asked the woman what she had fed him. "Water and sugar," she answered. After a few minutes of CPR, I gave up. There was nothing that could be done.
"He is dead, my dear lady," I said.
"But he is warm," the woman pleaded.
"For God's sake."
"I swear to the same God -- he is dead."
The woman was the infant's aunt. The father was in jail for drug trafficking, the mother was sick, and the aunt was the only refuge for the child. Out of desperation, she had given him water and sugar, so much that it had suffocated him. Perhaps something could have been done if he had been brought in an hour earlier. Perhaps something more could have been done a few days earlier or even a few months earlier, before he was born, but by the time he was taken to me it was already too late, much too late.
As I filled out the forms to transfer him to the morgue, his aunt was speaking to another of the infant's relatives. Pointing in my direction, she said, "They killed him." I wanted to answer, "You killed him," but I just said, "He was dead," and suddenly I burst into tears, the events of the night having finally gotten the best of me.
The last hours of my shift passed quietly. I was seated behind my desk, exhausted and burnt out. The emotional and physical toll of the preceding 24 hours coupled with a sleepless night had left me a wreck. The sun rose slowly from the horizon and redness crept upon the deep black of the sky. The morning-shift janitor started to wash the floor of the ER, the foul smell of ammonia awakening me fully. And then finally relief: the next doctor came to take over from me and my shift was done.
Being a doctor in Iran is not as rewarding as one might think. As I said, the work is hard and the pay is not good, especially for us GPs. But the really hard part is that you are reminded every day how little you can do and how dependent the well-being of individuals is on the uncertain commitment of society and government. People here have a right not to be pleased with the healthcare system. A country with such vast natural resources should be able to take better care of its people.
Ashfia Hasani is a pen name.
Copyright © 2012 Tehran Bureau