People prefer not to notice these places - psycho-neurological institutions (PNI). And very rarely does the public find out what is really going on there.
We publish the correspondence of volunteers with a doctor from one of the Ukrainian psycho-neurological institution during 2015-2019. This institution was far from civilization, 40 km from the nearest town.
This is a story about the attempts of a caring person to do something in the environment of poverty, corruption, ignorance and indifference of society to the fate of people with mental disabilities.
The doctor worked in this institution for about 4 years - longer than all other doctors. The psycho-neurological institution was closed, and the doctor went abroad. But more than 140 such PNIs work in Ukraine. About 28,000 people continue to live in similar conditions. Our project helps make a difference.
Some excerpts from the letters:
“The situation with maintaining my hygiene is anecdotal: for example, a couple of hours ago I was washing in a river located a few kilometers from home, returning home after dark, I risked stepping on a viper. Similar nuances to some extent explain the reluctance of doctors to physically be within the psycho-neurological institution”
“To the chief physician of the district hospital (CRH): Your specialists, especially in your absence, seem to have gotten into the habit of refusing hospitalization for wards, sometimes seriously ill. Why is this happening? Our wards simply have nowhere to be treated permanently, except for you. The psycho-neurological institution (PNI) does not have the ability to pay an informal, tax-free fee to a doctor in a hospital!”
“Doctors of the CRH use their experience, knowledge and considerable intellect to prove the alleged inappropriateness of hospitalizations (for people with mental disabilities), to unsubscribe, accuse or collect dirt on our psycho-neurological institution.”
“Several wards, despite all efforts, died. The situation was difficult, I even offered to call a priest to consecrate the problem building. At first, in the form of a stupid joke, and then in earnest. The priest arrived, conducted the consecration, and after 3 days the deaths ceased. They didn’t die in the psycho-neurological institution itself, a seriously ill patient was already in the hospital, he died a day later ... ”
“I also consider the impotence of modern psychiatry, which shied away from the extreme of the parallel punitive-repressive machine to the extreme oа weak structure, unable to provide adequate assistance to a sick person who is dangerous for himself and others because of the above-described right to lawlessness of this very mentally ill person, to be a big problem and evil. ”
“Recently, the ward, overwhelmed with delusional ideas, decided to massively improve the health of everyone in the psycho-neurological institution using urine therapy and, they say, poured urine into the place of the general intake of drinking water. In the end, he was severely beaten. And only then did it become possible to hospitalize him.”
“Now the director of the psycho-neurological institution is hounded by endless courts, and more than the European Union and the United States, he afraid of the nurse who terrorizes him. Therefore, he can refuse the arrival of foreign volunteers so that this nurse does not find a clue to complain about him again or sue him.
“I feel like a lonely Don Quixote fighting windmills. I became embittered, hardened, and even began to understand well the radicals, people from places not so remote, and even terrorists... As you can see, this is no good. So I'm asking you to fire me."
Detailed transcript of letters:
Chief physician of the CRH
I am a resident of the village of O., Petr Nikolaevich N. I work as a general practitioner in the PNI. I appeal on my own behalf, the administration of the PNI, unfortunately, has nothing to do with this appeal, and therefore I ask you to give me an answer personally to this e-mail address. I am addressing, however, officially, and therefore I ask you to give an official answer; on a question related to my work and the work of your subordinates.
From the moment you took office at the Central District Hospital, I, who, by the nature of my work, are in close contact with the work of the medical staff of the Central District Hospital, have noticed positive changes visible even to an outsider: it seems to me that the discipline of doctors has increased in general. So, for example, when I recently brought patients with acute toothache twice, emergency dentists were brought from home, which was simply unthinkable under predecessors. So there are no complaints about dentists, as well as the surgeon and the surgical department.
Normally, we are also received by other specialists when it comes to outpatient appointments. We are also pleased with the fact that now, when we are discharged from the hospital, they still write discharge epicrises to us, and earlier, it used to be sent home only with good parting wishes not to come again.
However, during Your absence due to illness, the problem of the passionate unwillingness of the departments of the hospital, except for the surgical one, to receive the inhabitants of our PNI has aggravated. As you know, in our medicine there is such a well-known, but not officially recognized phenomenon as discrimination against patients on the basis of material security. Medical institutions of the tertiary, and some, it seems, of the secondary level, are unwilling to provide quality medical care to patients who are unable to pay for treatment, and, in most cases, the unofficial doctor's fee. Our wards simply have nowhere to be treated permanently, except for you. Often, having made a long thorny path of sendings from doctors of one medical institution to doctors of another, which began with you, we also bring the exhausted patient to you (wards S., B., etc.). However, it begins to seem that it is no longer possible for our wards to get into the Central Regional Hospital!
Your specialists, especially in your absence, have become accustomed to, probably, they will refuse hospitalization for wards, sometimes seriously ill. Why is this happening? All this leads to the sad thought that some physicians may have higher views on the need to discuss the problems of psychotropic diseases. Maybe they don't want to port the statistics of those dying in the departments by wards? Or maybe you don’t want to rack your brains over the problems of patients who are difficult in diagnostic and communicative terms? After all, we provide medicines, food, sanitary support, transport to other medical institutions and the mortuary of our wards!
The only thing we haven't been able to do yet is to pay the unofficial, tax-free hospital consumption fee!
Instead, the doctors of the department use their experience, knowledge and considerable intellect to explain the alleged inexpediency of hospitalizations, unsubscribe, accuse or collect dirt on our psycho-neurological institution.
So, on May 14, I was called to the patient K., 58 years old, who was unconscious, with a febrile temperature, noisy, frequent, hoarse, bubbling breathing, up to 40/min, retraction of the intercostal spaces, pronounced asymmetry of the face. This was not the first time such a sudden deterioration in his condition had happened to him, but never before during my observation had it been so pronounced. Only in the last month already twice, and twice he was in the intensive care unit. Me and the nurse, of course, provided assistance and called the ambulance team to transport him to the Central District Hospital for medical treatment. As a result of the medical care provided, the patient felt better, he even regained consciousness, was in a sopor, tachypnea and tachycardia decreased. At the height of these symptoms, he was transported to the Central District Hospital. There he was also examined by several specialists who did not find what and where to put him and did not find anything better than to send him home! At home, upon arrival at the psycho-neurological institution, the patient found himself unconscious and did not wake up until the next morning. Just in case, I filmed it, if anyone disputes that, they say, there was no evidence ... they were forced to organize resuscitation at home and spent several hours infusions with a total volume of about 1.5 liters, as a result of which the patient's condition improved. I pre-empt the insinuations that the patient did not eat or drink. He ate and drank the previous day, albeit in less quantity than usual!
How would you describe the actions of doctors in relation to a patient under the age of 60 years? Maybe passive euthanasia?
Therefore, summing up, I have the audacity to ask you to look into this situation, not so much the past as the future situations, so that some of your subordinates are not engaged in collective mutually insuring search for the lack of indications for hospitalization, not teaching what should have been done before and asking rhetorical questions why we brought a patient to them, not by collecting compromising materials for the psycho-neurological institution, but by our direct duties!
Whether they like it or not, whether they or I will work or not, but there is a PNI and there is a Central Regional Hospital, and our institutions are simply doomed to cooperate! Preferably constructive...
Sincerely, Peter N.
I just sent you copies of my Complaint to the head physician of the Central District Hospital about his subordinates, which I wrote to clear my conscience, not believing that I could change anything in the trend of the swine attitude of the medical institution towards patients. Most likely, there will be no reaction. Perhaps it will hit me with a boomerang, so I will be to blame for everything, incl. and in the collision of comet Schumacher-Levy with Jupiter ...
I also want to add a fly in the ointment to the unconditional positivity of the activities of volunteers. So, recently a volunteer came and, according to the attendants, generously fed the wards supervised by her with all sorts of sweets. After that, T., according to the staff, had profuse vomiting in the evening and diarrhea at night. The very next day he fell into a coma. Probably due to dehydration. This is not from words, but I am a witness. They provided assistance on the spot, called an ambulance. He was more fortunate than the patient for whom I wrote a complaint, and therefore he was put and treated in the hospital. Now his condition is the same as before ...
Please take into account and voice to everyone who wants well that the wards of psycho-neurological institutions, at least the 3rd building, are not just a little different, but rather seriously ill, having not just intellectual, but also multiple multiple organ failure and overfeeding them with sweets, smoked meats, etc. sometimes just dangerous...
Memo to the Director of PNI
Now it's the 21st century! The age of scientific and technological progress, the Internet, bio- and nano-technologies! Also, I will not make a discovery that in modern civilized countries hygiene has long been an indispensable feature of any, at least somewhat socially adapted person. The absence of the latter is strongly associated with alcoholics, drug addicts and the homeless. A daily shower, sometimes even twice a day, no longer seems like a luxury, but is a routine procedure there. Also, one could not remind about the importance of hygiene in such professions as a salesman, a catering worker, a doctor, etc…
At the moment, in the departmental apartment in which I live, there is no elementary water supply, shower, bath, toilet, sewerage. In the conditions of water supply of the standards of the Middle Ages, one can only speak of proper hygiene with a smile. This fact, in the case of my profession, therefore becomes not a personal matter, but a matter of work necessity.
Therefore, I ask you to positively consider the possibility of supplying water to apartment No.X.
The situation with maintaining my hygiene is anecdotal: for example, a couple of hours ago I washed in a river located several kilometers from home, returning home after dark, I risked stepping on a viper, etc.
Don't you think that such nuances to some extent explain the reluctance of doctors to be physically within the psycho-neurological institution, even if they formally work in it?
In the event that the supply of water immediately to one departmental apartment with plumbing places such a monstrously heavy burden on the budget of the psycho-neurological institution, I ask you to at least make a drain so that you can drain the slop and not engage in dubious fitness with buckets, taking them tens of meters into the trash and dung heaps!
Petr N., therapist
I also ask you to take into account that although the living conditions of a doctor are important, I consider the actual inaccessibility of medical institutions of the tertiary level, and now of the secondary level for inpatient treatment of wards of psychiatric hospitals and disabled people in general, as well as low-income people without disabilities, to be a more grandiose, urgent and threatening problem. Possibly?, discussion of this problem on the net, publications indicating specific hospitals as examples could have a wide resonance ... Now, in the age of the Internet, public opinion and drawing negative attention matters. Perhaps, after such discussions with the name of specific hospitals, their attitude towards the wards would have changed at least a little ...
As you asked, I will briefly describe my wishes after work ...
In general, my impressions of what is happening in PNI and FTO remained approximately the same, I will repeat ...
Coming to work was at the initiative of the director. As I thought, as I told you, and as it turned out, the situation with patients and work was difficult: some patients of the 3rd Corps were seriously ill and began to die. The doctors of the Central Regional Hospital - CPMSD did not want to seriously treat them in the hospital, they came rarely and reluctantly.
Therefore, the load on the medical staff in the first 3 weeks in the 3rd building increased unusually. Also, consultations, hospitalizations, ambulance calls, as well as conflicts with the Central District Hospital, ZOKB, 5 GB have increased dramatically because of my desire and their unwillingness to seriously provide inpatient medical care to the wards. Several wards, despite all efforts, died. The situation was difficult, I even offered to call a priest to consecrate the problem building. At first, in the form of a stupid joke, and, then, in earnest. The priest arrived, conducted the consecration, and after 3 days the deaths ceased. They didn’t die in the psycho-neurological institution itself, a seriously ill patient was already in the hospital, he died a day later ...
Then, the situation turned around and the deaths stopped. I will not unequivocally state that the Higher powers helped, but I really want to believe in a Miracle! I will also not, especially, argue that a sharp improvement is my merit, although I, I hope, also somehow involved in this. One way or another, but since then and up to my departure, no one has died ...
In general, as I have repeatedly written, the big problem of modern care for wards is the humanistic populism and double standards, the falling out of the mentally ill from the legal field, their danger primarily to themselves and other wards, as well as to the mentally healthy, which, I must say , are also people, and should also have rights ... In fact, the most noticeable is the de facto right to arbitrariness that has reappeared de facto. Real rights, such as the right to normal, modern medical care, the right to work, the right to safety from their own kind, and also to safety from themselves, have significantly decreased due to new trends ...
I also consider the impotence of modern psychiatry, which shied away from the extremes of the parallel punitive-repressive machine to the extremes of the weak structure, unable to provide adequate assistance to a sick person, dangerous to himself and others because of the above-described right to lawlessness of this very mentally ill person, to be a big problem and evil, I also consider it a big problem and an evil.
My words are not empty words: just last month, two serious group beatings of wards of other wards took place in the psycho-neurological institution. One of them, who is incapacitated, is already being beaten for the second time. The fact is that he refused to take psychotropic drugs, did not allow anyone to live, and it was impossible to hospitalize him, since he did not want to and only through the court. In addition, infuriated by delusional ideas, according to the wards, he decided to massively improve the health of everyone in the psycho-neurological institution by means of urinotherapy and, they said, he poured urine in the place of the common intake of drinking water! In the end, he was badly beaten! And only then was there an opportunity to hospitalize him!
The first time, a year and a half ago, he was beaten under similar circumstances in such a way that a 12 liter metal cylindrical bucket was bent over his strong head!
A rhetorical question arises: are such rights necessary for the mentally ill, and is such psychiatry necessary?
On the issue of the availability of medical care, I have spoken and written a lot, and I affirm that adequate, modern medicine is not available to wards without financial relatives. I am happy, however, that the ward B., the very one whom I drove around I. and Zaporizhzhia, was still taken back to Zaporizhzhia, already for the third time, and he was operated on...
Therefore, it is not surprising that the number of medical workers who want to work in these areas is declining ... And it's not just about miserable salaries ...
In general, the need for a doctor, especially a psychiatrist, is very great. Of course, the director needs to look for it ... Announcements should be placed on commercial sites, not official ones. Of course, it is necessary to solve the issue of water supply, sewerage and the Internet. Without the latest, lamentations about the absence of a doctor seem ridiculous to me ...
Maybe you need to make some kind of intelligible efforts for this psycho-neurological institution? In general, even with a slight increase in income and the installation of a sewerage system, the possibility of a long-term presence of a doctor at a psycho-neurological institution seems doubtful to me ... A variant with an intern, or a migrant, or a pensioner, or an alcoholic doctor is possible ...
It’s rather inconvenient to remind myself on such an occasion, but I have to: I ask you to fire me with ...
This time I do not blame anyone; I do not put forward any conditions and do not blame anyone (and I have already succeeded too much in looking for specks and logs in other people's eyes) ...
I just can’t be free from the conventions and stereotypes of our time: my income level, social status, living conditions and “marital status” are almost the same as 18 years ago, when I just graduated from the medical academy ... It doesn’t matter who is in it guilty, the fact remains and I don’t believe that something will change for the better here at PNI. Yes, and in Ukraine in the foreseeable future ... Therefore, if there is such an opportunity, I will try to go somewhere, although I have no illusions about this option either ... I would be grateful if someone could somehow help me with this ...
I consider fatigue and burnout from communication with employees, and not wards, endless and unproductive work to force people to work without having any authority to do this, a secondary, but also important reason. I feel like a lonely Don Quixote fighting windmills. I became embittered, hardened, and even began to understand well the radicals, people from places not so remote, and even terrorists... As you can see, this is no good. This does not completely disappear either from my trips to K., or from various ways of psychological relief, exercises (including religious ones), or even from vacation ...
I have already described other reasons in the problems and shortcomings in my monthly reports.
I don’t see any other way out, and if someone had tried to convince them, nothing would have happened, because unlike the last two times, this is not one reason, but a whole complex ...
In a psycho-neurological institution, a doctor is really needed, especially in the context of ever-increasing discrimination and the availability of medical care. Therefore, the leadership of the boarding school needs to take care that my follower has special prerogatives in terms of conditions and income, regardless of any envy of the local residents and that the doctor has the authority that he should, feels like a doctor, and not Don Quixote among the mills above and below subordination.
Another option is to invite an intern for distribution. Then it is possible without special prerogatives, he will work for a year, maybe all three ...
In the end, I would like to express my gratitude to you for a rather long cooperation…. Because there was more order here. For not lying to me and not promising what they could not deliver. For support in the conflict with N.
For a tolerant attitude towards my stubborn character and especially for a tolerant attitude and the absence of attempts to rape my so archaic, outdated and intolerant worldview ...
In any case, I would be glad to receive recommendations, if possible, assistance in finding employment outside of Ukraine, do not burn bridges and I do not exclude the potential possibility cooperation in the future...
Yesterday, when I asked about mortality, I forgot and gave not entirely correct information: one of the two deceased was young, disappeared on a winter evening, they were looking for the whole psycho-neurological institution, they found a body in the morning near the landfill. At the autopsy, it turned out that he choked on cotton wool from diapers and plastic (according to the results). I reported about this case in the reports ...
I provide a list of the main problems and the proposed way to solve them in the work of the medical department of the PNI, my personal work, as of September 22, 2016 in my subjective assessment, as concisely as possible. At the same time, I omit the majority of problems that we will not be able to solve in any case, and which, in my opinion, are predominant (I see the main reason in systemic and grandiose phenomena, and not in the mistakes of specific people).
1. Lack of incentives and responsibility for the work of health workers.
Employees know perfectly well that no matter how well or badly they work, they will not get anything good or bad for it. There are no bonuses or reprimands or promotions. Such leveling, which the Soviet system did not know, completely discourages the desire to try to work.
2. Lack of a clear concept or lack of it about the basic principles of employees, such as general ethics, humanism, deontology and, especially, subordination at work among employees; lack of intolerance towards violators of these principles in the administration.
3. Lack of direct levers of influence on subordinates of the doctor.
4. Compliance with the doctor's job description by the administration
Too much is asked of the doctor, but not a single serious leverage. Only words, reports, etc. The doctor, in accordance with his job description, has the right to demand reprimands, to remove him from work. These powers of mine are ignored by the administration (they are observed purely formally), because I always demand enough, I demand, and then nothing is done ...
5. Weak control over the wards, the lack of clear tactics in case of their violations of the regime or frankly hooligan actions, theft, alcohol consumption and the lack of clear tactics in such cases +
it is necessary to involve a male orderly +
6. Lack of funds for medicines. It is necessary to increase their number.
7. Not always timely delivery of medicines by the supplier. Contributing to the timeliness of this delivery, concluding contracts with a competitor.
8. Intervention of non-medical workers in purely medical matters, assessment of the doctor's activities by those who do not have the education to do this.
9. The reluctance of medical institutions to hospitalize wards in some cases.
10. The problem I have described in previous posts. conduct in-depth testing when hiring, identifying, first of all, the moral qualities of employees, tk. they work with people, not chess pieces (there are tests that exclude the conscious embellishment of a loved one). Probably, a permanent work of a psychologist is needed.
In my opinion, these qualities should be preferred when working with people...
11. An increase in the level of general aggression, disappointment and nervousness, an emphasized critical attitude of employees to any orders of any superiors, rejection of any control over their work
(the doctor was accused by officials of having a large amount of unused medicines in stock at the boarding school)
By the presence in the pharmacy of the PNI of a "large" amount of medicines, etc., I explain:
According to the latest data, the boarding school pharmacy contained medicines worth about $ 2 302 on the balance sheet. This happened due to the fact that at the end of 2015. too much money was allocated for medicines (at those prices). At the end of the year, it was necessary to use the funds that were on the balance, so everything that was considered necessary at that time was purchased, taking into account the prospect, as far as it is possible to foresee the need for medicines in the future.
I did not want to do this even then, because. Even then I foresaw future inconsistencies, since some medicines would be spent more, and some less, moreover, this is the responsibility of the senior nurses, and not the doctor.
This year, on the contrary, too little money was allocated for medicines, about 3 (!) times less than last year, and the prices for medicines have increased.
Therefore, no matter how many medicines are left, long before the real problems, I predicted in my reports to the Fund that problems with the provision of medicines were inevitable, because. little means little, and it never becomes much or enough. I use mostly the same medicines, I prescribe a few new ones. If only I made the appointments, then there would be fewer problems with the provision of medicines, because. I would prescribe mainly those medications that are available. Problems arise when appointments are made by consultants who proceed from their own medical considerations, and not their presence or absence in our pharmacy. At the same time, there is also a new problem that the acquired effective antibiotics (ceftriaxone), widely used in medicine, turned out to be ineffective, it is necessary to purchase more expensive and highly effective antibiotics (ceftazidime, etc.).
It was absolutely impossible to buy all possible options for medicines last year, because. too many of them. It is not always possible to replace the recommended drug with an analogue. Often there is no analogue with the same chemical composition. I do it whenever possible. It is also not always possible to replace the recommended drug not with an analogue, but with a drug similar in effect. In this case, it makes no sense to advise wards at all, because I myself prescribe similar drugs. The meaning of the consultant is to prescribe the most optimal specific and effective drug.
In general, the availability of medicines for the indicated amount does not seem so big to me. We have disabled wards, the very fact of their being in a psycho-neurological institution indicates that they have serious illnesses. We have over 140 of them! The example of other psycho-neurological institutions does not seem too authoritative to me: If the wards are not consulted anywhere, treated with iodine, analgin and brilliant green, then there will be tens or hundreds of hryvnias, not thousands, on the balance. Do not forget the fact of inflation: $ 2 302 today - it's not $ 2 302 yesterday.
Providing medicines in our country has problems not only of lack of funds, but also of untimeliness between ordering medicines and receiving them. If the amount for which medicines are ordered is small, wait, when they are delivered, it takes a long time, despite promises to do it "tomorrow". Sometimes their receipt is no longer relevant - the condition of the ward improves by itself, with the presence of what is. However, the situation may go according to a different scenario - the ward may die without waiting for adequate help . Sometimes medicines are needed today and now, and not next week.
At the same time, there are constructive and destructive ways out of this situation.
"Exit" first, destructive:
1. Make the doctor a "switchman" and blame him for the ineffectiveness of ordering medicines, his inability to foresee the situation.
2. Forbid the doctor to advise the wards of narrow specialists, so that they do not prescribe a variety.
3. Shut the doctor's mouth so that he does not ask for funds for medicines.
4. To report everywhere that everything is fine with us, there is enough of everything, to have on the balance of medicines in the amount of $ 1354 etc.
5. Due to the inevitable negative consequences for the wards of such a policy, blame only the doctor, but not the scarcity of allocated funds, the slowness of the bureaucratic system, the monopoly etc.
Second output, constructive:
1. Recognize the cause of the problem as a lack of funds, red tape in the acquisition system, etc.
2.. Do not pretend that everything is fine with us, and if anyone is to blame, then the "switchmen".
3. Try to transfer money from other budget items for medicines.
4. To have more money available to purchase medicines with their subsequent reimbursement from the accounts of the wards.
5. Make great efforts to purchase medicines from these accounts, anyway, many of them have them as a dead weight in huge amounts for the benefit of banks, and not these wards.
6. Find a competitor BADM without terminating the contract with him, so that he would not be a monopolist and move faster, knowing about the competition.
Summing up the above, it seems to me not entirely correct that I should generally give explanations on this matter: deals with the purchase of medicines nurse and accounting, but not a doctor. This is not his duty. In the doctor's job description there is only an item: "Introduce administrative propositions about ... the safety of the medical document with faces ..." This item is in Functional rights, not duties. This is his right, not duty.
In addition, it is impossible to demand from a person to be a prophet and to know exactly when, how, what the wards will fall ill next year and what, how much and how much medicines will then be used.
For myself, I made the following conclusion: there is no need to get into the provision of medicines at all, because. It is the doctor's job to treat with medicines, not to buy these medicines so as not to be a scapegoat due to poverty, bureaucracy and impossible requirements ...
I ask you to take into account one more nuance in the failures in the provision of medicines to the wards: the lack of the entire set of medicines that is ordered.
So, for example, the story with the acquisition of ceftazidime, which had a resonance. Due to the need to purchase it as soon as possible, it was ordered from BADM, urgently. The order was processed and brought unusually quickly - literally the next day! Not only ceftazidime was ordered, but also other drugs at the same time.
The brought medicines had everything, except for what the order was made for, i.е. everything, everything except ceftazidime! Therefore, we still do not have it, we manage with what we have, distant analogues, the effect of which is much weaker -
- children continue to get sick ... This curiosity is not the only one: for example, I have been waiting for the ACC drug I ordered for about half a year, in vain ...