Violence that brings out violence in me….

I work in a context where there is always loud voices and non-physical violence (verbal violence) as part of the health care context.

Yesterday morning walking into ICU – this patient has been with us for 10 days with a Chronic Meningitis and encephalopathy. There was that one particular distant relative, who has been consistently “irritating”. He would walk in and out of the wards, OPD catching you in the corridors, or any other doctor and trying to ask questions, asking for surety of success, shouting at the nurses over last 10 days. Our team had offered that the patient be referred to a higher centre, but the same person would say yes once and then turn around and decide against it. At the end of this multiple dilly dallying I decided time has come to stop and put an end to this. I called him aside and had gave him a verbal show down, whereby I asked him to make up his mind regarding taking patient off or keeping him with us. Now after 10 days, we were sending the patient home, not too okay, for home care. I was to talk to the relatives, and I was detesting talking to the same man again! Hoping that some other relative will come in, I called for relatives. And this man came! After all the explanation, with inner anger and irritation well masked, (an art that we all master soon), we made plans for discharge. Then he turned around and said, I hope that in all your decisions, my way of talk has not affected your decisions in any way. I want to ask forgiveness. I was sure that even this statement had ulterior motives! And waited for the next statement. That was for concession in the bill. But the team had already shared, we should not be given any concession, not because of their ability to pay or not pay, but because of the arrogance of this one man.

Later in the evening the truth dawned, his verbal violence, which was normal for him and he had recognized the same, had created internal violence in me, and my decisions were affected by this internal violence…. He had the humility to recognize and ask forgiveness, may be for a selfish reason, but I had taken 12 hours to recognize our own internal violence, by then they were gone….

Walking to the next bed, I was already primed. Very poor patient, in cardiogenic shock and severe bradycardia, the husband had a come in and shouted at the staff, accusing them of stealing their medicines! My mind was already made up, that I would not tolerate such behaviour. After sorting out the patients issues, I called for the relatives to come in. And this man and his brother walked in. Before even talking about the patient, I straight away addressed the behaviour issues of relatives! And then talked about the patient. But the talk about the patient did not go well. Their non-verbal response was one of “resigned arrogance”. They had no resources to go anywhere else, so they were stuck with us, at the same time, it was clear that they were offended by the way we were talking to them! And covering for the husband the brother said, continue the care, we will stay. As team we were talking to each other – how arrogant they are…. expect problems…. but little did we realize that behind the visible arrogance there might be other issues for them – the TINA factor.

For the poor, There Is No Alternative - than to put up with us the care givers whom they do not understand, and this discomfort presents itself as arrogance and violence….and we do not recognize of understand their discomfort….and allow that to make us internally violent….

I walked into the ward, and the junior Doctor was fuming with anger. He told, I am referring this old man, we cannot take care of him. The issue – well of family, father admitted with LGI bleed, needs blood, many relatives walking in and out, but none willing to give blood. The casual attitude and non-caring attitude of the relatives had angered the doctor who was caring for the patient. And his response was – send the patient away. A natural response -  why should we care if they do not care…I would have done the same, if I was the care provider. But something stopped me in my response. I saw the face of the wife, she in her 80s, sitting beside her husband….With no ability to take control of the situation, children were in control deciding whether to give blood or not. She would want to do everything, but was in the hands of her children who seemed to be slow in their responses….We discussed, should we put the patient at risk because of the careless attitudes of children? We decided against sending the patient off….

Careless attitudes of others which precipitated potential violence in us, but careful reflective thinking which prevented us from acting in violence….and that thinking facilitated by the vulnerability and concern of the wife, who wanted the best for her husband….

There were couple more such instances the same day….and I was left wondering – who was more violent – me the care provider or the people who access our care….?