In the time of Stalin in our country you wouldn’t have found a family in which no one was in prison. This was the epoch of awful repression, poverty and crime. In one prison cell you could find a murderer and a scientist, a journalist and a robber, someone who had returned from captivity after a war only to be denounced as a spy sitting next to one who was guilty of rape… “A half of population is imprisoned and another half guards,” — people gloomily joked in a low voices in their closed kitchens.
Because of that, something has changed in the mentality of our society, and prison’s formula “don’t trust, don’t fear, don’t ask” has become common everywhere even outside prison. Nowadays life is safer and easier, but this behavioral pattern was so deeply ingested in our subcortex that it switches on at the very first signal. This is the only way to safeguard your own inner freedom when you are in prison. I felt it very much and was not surprised that although the prisoners, especially the runners and the orderlies, were extremely polite, everybody sought to show the distance between us at the first opportunity. And it was strange that I unconsciously accepted the rules of that game: it seemed natural for me that the orderlies mustn’t ask questions and must be very attentive and prompt.
The subtleties of the situation came to light was when I was carrying a box with packs of blood for transfusions through the territory of prison to the hospital. The box was heavy and I asked the runner who accompanied me if he can help. “No, — answered he with obvious pleasure, — I have AIDS”. OK. But we both understood that the dangerous virus could not be transferred to the blood if he touched nothing but the box. I didn’t suggest that he deal directly with the blood. However it was a great chance for him to say “no”. In the life when you must every day say only “yes” there is a risk to lose the sense of self-esteem. So I just proceeded to carry the box by myself. It was my mistake to ask him for help and give him the opportunity to refuse.
However I learned quickly. During my second night, when I was the only doctor on duty in the hospital, the guards brought a prisoner who had wounded his arm on a woodworking machine. The orderlies put him into the operating room. While I was preparing to treat the wound, one of the orderlies, the young boy, embarrassedly asked me:
— Doctor, which educational institution did you graduate from?
I imagined how they didn’t sleep at night deciding who of them will ask me something like this and grunted grimly:
— Three years of the parochial school.
— Me too! — He guilelessly beamed while his partners slightly creased their lips in an inconspicuous grin. I said nothing more but saw how he was trying to hide his naive and glad smile. My direct answer had given them a small victory and made me the butt of their joke. They knew they shouldn’t ask and that I shouldn’t answer. But they did, and I had. Chalk one up for the inmates — they had successfully violated one of the unwritten rules.
Unfortunately that case was not the only one on my second duty, and in fact that night was overshadowed by a very unpleasant situation. When I came to the Department of Therapy while making my rounds, a nurse said that one of the patients had a terrible edema. He was bad enough so that he couldn’t be moved, and I came into his ward. I saw a young man approximately 20 years old whose tissues were manifestly swollen. He spoke with a big effort and breathed heavily.
— How long it has been with him? — I asked, glancing at his documents. He was hospitalized with a diagnosis “ankylosing spondylitis” —the disease which deforms spine and joints. The edema was not indicated in his papers.
— About three days, — the orderly answered, —and he gets worse.
I found a list of his treatment and noticed that they had been given him a low dose of diuretic in tablets. Too low of a dose!
— Does he urinate?
— No, —my interlocutor answered, — about two days.
I palpated the patient’s abdomen: his bladder was empty. It seemed like his kidneys couldn’t manage and all liquid had moved into the tissues. I urgently prescribed him a high dose of diuretic in injection and went to a staffroom. There I made a call to our resuscitator to consult because I had received training as a traumatologist and had only common knowledge in therapy. Nadezhda was asleep but quickly oriented and told me in detail how to treat a patient in that condition.
— As it appears, time is lost, — she added, —I can’t predict the result.
I gave her thanks and began the treatment. The nurse, orderlies and I twisted around him all night, but he was getting worse and worse. First we gave him required medications, tried to catheterize his bladder, a few hours later tried to reanimate him… In the early morning he finally fainted and two hours later stopped breathing. His lungs just drowned in the inner liquid.
In the morning my colleagues found me with the paperwork. After a several questions they understood what had happened.
— What do you write as a reason of death? — The head of hospital, Valery, asked carefully.
— Renal insufficiency and pulmonary edema, — I answered. They looked to each other.
— The therapists treated him with the different diagnosis, didn’t they? — He clarified.
— Yeah, they did. And he didn’t receive the treatment he needed all those few days.
Valery went out of the staffroom and returned a little later.
— I spoke with them, — he said calmly. — Could you please write the ankylosing spondylitis as a reason of death?
— Of course, no! — I exclaimed emphatically and with a hint of anger. — They must diagnose right, and he could be alive now if they had given him the right medicine in the right doses! They have these drugs, I saw it tonight.
He said nothing but I saw that he was confused. Several minutes later the phone rang and somebody got me. There was a Chief of the Department of Therapy. She asked me the same question: what I write as a reason of death? When I answered, she suddenly started to shout.
— Could you look into his documents?! He had another diagnosis!
— It was wrong. There was not the data in his papers that he had an edema during the last days and that he didn’t urinate. The main diagnosis must be the renal insufficiency! — I protested, shocked by her obstinate and uncooperative tone.
— Are you a therapist?! What do you know about it?! You must write the ankylosing spondylitis! Yeah, he had a little edema, but we gave him the diuretic!
— No, I can’t do it. I don’t need to be a therapist to see that it was not enough for him! He needed big doses by injections and you should have given him another medicines too!
— You are half-educated selfish upstart! — She hissed into the phone with anger. — If you are such a fool, it is a reason to learn more and to be out of our business! — She hung up.
I had thought that I was thick-skinned and poised enough, but in that minute the night without sleep and injustice of her words hurt me so hard that I couldn’t hold back the tears. It was doubly offensive that I quietly cried in Valery’s presence, as a little girl but not a serious doctor! Valery silently made a cup of tea for me.
— It is unfair, — I said when I became able to say something more or less calmly. — It was their mistake, not mine. I don’t want to cover them! Moreover, the body will be sent to a pathoanatomical examination and there everything will become clear. If the pathologists ask me why I wrote a wrong things, what I would answer? It’s an obvious pipsqueak, the same as we write: “He died from scoliosis”! Nobody dies from scoliosis!
— Listen, please, — Valery said softly. — This is a closed system and it should stay stable. If you write the right diagnosis, some questions will appear. Why they didn’t treat him properly? It is negligence and we will lose one or two doctors. Who will work? The salaries here are too low and the conditions are too bad. It’s so difficult to find a doctor who is ready to work here.
— …but the examination of body!.. — I was puzzled.
— Pathologists will confirm any nonsense we write. They have been doing it for years because otherwise all our system will begin to stagger.
— We jumped around that guy all night and he died! They have been doing nothing for three days as if he wasn’t in their department! And now they afford themselves to tell this shit to me and I have to cover them! I won’t!
— If you want, I’ll press them and they will apologize…
I felt confused and insulted, but by then we had been smoking, drinking tea and conversing about one hour. Finally, my idealistic defenses wilted and I did what all of them wanted. Yes, Valery made sure that the Chief of the Department of Therapy said to me “Sorry” although I hadn’t asked him for it. My conscience is unclean since then and I don’t know if I did right when I finally wrote the wrong diagnosis.
The second night duties turned hard for me and it was associated with the second death. What did the universe want to tell me? What was waiting for me further?
To be continued