When patients turn a blind eye to your expert advice

Wednesday December 19 2018

Dr Lugano Wilson

Dr Lugano Wilson 

By Dr Lugano Wilson

Following a doctor’s treatment plan or instructions is very important to achieve good health and relief. While some physicians try to minimize problems by not telling the patient the whole truth, there are those who prefer being straight forward. This is debatable. But it is important to have an open communication with the patient and take their consent in whatever treatment plan or procedure you ought to give or do. It’s important to not only get their feedback but also make sure they have understood the whys and hows.
But as doctors, we also come across patients who despite consenting and understanding, don’t follow instructions. And this tendency is quite common. I came across one of them, an old man aged 70, few weeks back who refused to follow instructions. Here’s his story.

It was an emergency
The old man who visited our facility was referred from Mwananyamala hospital. He was diagnosed with an emergency medical condition known as “peritonitis” for which the old man presented with abdominal tenderness and distension, constipation and vomiting.
I was asked to visit and review this patient on the verge of emergency surgery. It was rather an urgent matter, thus I had to be there in no time. We began the the preoperative preparation and evaluation tailored to his condition. I had to order insertion of the “nasogastric tube or NGT” [a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving a person extra calories] in order to decompress the bowel and for eventual prevention of airway complications before and during surgery.
Did he accept the idea of putting a tube in his stomach? Yes, he accepted the idea though with difficulty. I don’t blame him; of course that process can make anyone uncomfortable. He was very anxious and looked terribly upset.  
But I had to remind him from time to time that this tube was life-saving, and it does more help than harm.
Passing of this tube was not easy as he was full of flurries despite he had been counseled and he consented to the procedure. While at it, I remember he screamed in the procedure room saying, “wanataka kuniua” (loosely translated in English as ‘they want to kill me’).

What was done?
We allowed him to blow his nose and take a few sips of water whilst on bed. During the whole process we kept his head, neck and body bent at various angles as the need dictated and as we threaded the tube ultimately into the stomach. This helped ease our previously-thought herculean task and kept our patient out of pain and his much-awaited discomfort, thus in the end we confirmed the correct tube placement, kept and secured it into place.

Why was the tube inserted?
Let us first look at what it is. This is a plastic tube that is inserted through your nose into your stomach.
The tube can be used to remove  some of the stomach contents to relieve some pressure on an intestinal obstruction or blockage, it can also be used to remove blood from your stomach, remove  a sample of  stomach for analysis, or it can be inserted in patients who are comatose, neck or facial injury, and  in those who might require a mechanical ventilator to breathe into the bargain.

He removed the tube
Just before the surgery, I found the patient without the tube. Giving him the benefit of doubt, I asked the theatre nurses if they had removed it without consent. But they all refuted the claim.
Having seen us asking about the matter, the old man started trying to silently insert the tube. My colleagues and I were surprised as we have never come across a patient inserting a tube on their own. Unfortunately his efforts ended in vain, thus we humbly resorted to re-inserting it ourselves without even condemning the patient for the matter.

Dr Lugano is a medical doctor, public health activist and researcher based in Dar es Salaam.