Sunday, Oct 26, 2014, 4:54 PM CST – China

Society

Hospital Attack

Inevitable Brutality

The vicious murder of a doctor in a Zhejiang hospital shows the multiple failings in China’s healthcare system

Lian Enqing Photo by IC

Staff from the No.1 Hospital of Wenling mourn murdered colleague Wang Yunjie Photo by IC

Before he made his last call to his doctors on October 25, 2013, Lian Enqing had returned to his local hospital more than 100 times after receiving what he claimed was botched nasal surgery 19 months previously.

Each call followed the same routine. Lian would complain that he could barely breathe through his nostrils, while his ear, nose and throat (ENT) consultant Wang Yunjie of the No. 1 Hospital of Wenling, Zhejiang Province, would do no more than advise him to take it easy, assuring the fretful Lian that his CT scan and other diagnostic tests showed no post-surgery abnormalities in his nasal septum. However, Lian continued to complain of pain and an inability to breathe.

On October 25, Lian returned again to the hospital, where he stabbed Wang to death and injured two other doctors before being subdued.

Dispute

In March 2012, to cure his rhinitis and a deviation of his nasal septum, Lian underwent surgery in the hospital, which lasted one hour and cost him 5,000 yuan (US$820), almost half his annual salary. His surgeon declared the procedure was successful, however Lian felt no better, and continued to complain of migraines and a feeling of suffocation. He reportedly stopped sleeping at night, and became anxious and depressed. Finding himself unable to work, he quit his job at a local manufacturer of mechanical mahjong tables and instead made repeated visits to the hospital where he had undergone surgery.

Successive examinations concluded that his nasal airway was clear, and doctors could find no cause for his claimed inability to breathe through his nose.

“Why do the doctors say there is no problem when my nose is torturing me?” Lian complained to his family. He began to mutter darkly that he had received a botched procedure because he hadn’t bribed his surgeon or his consultant – a common practice in China’s overstretched hospitals, where most staff members earn a minimal salary. Doctors frequently demand additional “fees” for treatment, or overprescribe medications or force placebos on unsuspecting patients in order to pad their salaries with sales bonuses. Disputes over kickbacks have led to a series of violent attacks on hospital staff by disgruntled patients in recent years.

In Wenling No. 1 Hospital, the largest, best-equipped and busiest healthcare facility in Wenling, a county with a population of 1.2 million, patients or their relatives would often queue up from four o’clock in the morning in the hope of seeing one of the hospital’s most reputable consultants.

Lian also told his sister that doctors looked down upon rural people, and had thus been slapdash with his surgery and treatment. However, his doctors insisted they were taking all the care they could, considering the demand for their time from local patients.

Like many such institutions in China, the No. 1 Hospital of Wenling is not insured against medical malpractice or accidents, and thus habitually settles disputes with patients by paying financial compensation, rather than resorting to the bloated and bureaucratic court system.

This approach often antagonizes doctors, as a compensation payment even when the medical practitioner is not at fault can ruin their reputations. Some patients’ families have even been known to hire people to make a scene in front of the hospital – even hauling the body of a recently deceased person before the main doors in a bid to extort compensation, regardless of whether or not the death was avoidable. With no clearly defined procedures to handle such cases, more often than not, the hospital pays up to make them go away.

The No. 1 Hospital also tried to settle Lian’s case by paying compensation, but an amount could not be agreed, and Lian continued to insist on a follow-up operation.

Only a Nose

 Lian’s need of money was obvious to everyone around him. He had been a migrant worker since finishing junior high. Now 33, Lian, single (his family felt he couldn’t afford a bride), had few possessions beyond a few lamps, an old TV set and a refrigerator – all of which he shared with his family. However, he genuinely seemed more concerned about his nose than milking money from the hospital he blamed for his pain.

Lian took his appeal to the hospital’s dispute-handling department. After re-examination of Lian’s nasal septum and further consultation, the department concluded that Lian had “unrealistically high expectations” of the benefits of his surgery. ENT department director Wang Yunjie, his future victim, was assigned to break the news to Lian. This would later prove fatal to Wang, as Lian directed his anger against this individual, rather than the system he believed had failed him.

In spite of regular meetings and constant explanations, Wang failed to get Lian to back down, or to perceive his pain as anything but real. Lian demanded regular examinations, as well as frequent CT scans, all of which produced the same result. The hospital arranged two group consultations, assembling the best doctors from all relevant departments and even inviting top provincial ENT surgeons along. No abnormality or obstruction was found.

Lian began to show signs of obsession. His family told reporters that whenever a guest dropped by, he would show them his nostrils and ask whether one was bigger than the other. He asked his mother to open his airways by sticking a chopstick into his nasal cavity, something she refused to do. He responded by ramming his head against a wall “to clear the blockage.”

“For him, it seemed that the only thing left in the world was his nose,” said Lian Enqing’s younger sister Lian Qiao, speaking under an assumed name.

Lian returned to the hospital again and knelt before his doctors, begging them to perform another surgery, but again he was rebuffed. Instead, they recommended he seek psychiatric help. This only served to aggravate him further.

Airless

Lian had worked himself into a frenzy. After visiting other hospitals in other cities only to receive the same diagnosis, he became convinced China’s entire medical industry was conspiring against him, using the Internet to guarantee he remained untreated. By this point, even his family had begun to suspect his problem might be psychological – otherwise, surely the doctors would have found something?

Lian would not be calmed, verbally berating anyone who dared to suggest his nose was okay. He began to smash glass doors and electrical items in his family’s home. He even started beating up his mother and sister, who were becoming terrified of him.

In August 2013, Lian was sent to a mental hospital in Shanghai, where he was diagnosed with persistent delusional disorder, and was hospitalized for two months.

“You sent me to cure a disease I didn’t have, but would not cure my real disease.” Lian reportedly accused his mother as soon as he got home after being discharged from the mental hospital.

“You think my nose is in less pain now?”

Since the murder, some experts have come forward to suggest that Lian may not have been imagining his symptoms, as his doctors believe.

His reported pain was consistent with the symptoms of empty nose syndrome (ENS), which results from the excessive removal of turbinates – tiny internal structures which regulate humidity, heat exchange, airflow control and air filtration within the nasal passages – something which can create a sensation of intense pain and breathlessness. The procedure carried out on Lian at the No. 1 Hospital was a full turbinectomy. This procedure, if not performed carefully, can lead to breathlessness and intense pain as well as anxiety and chronic fatigue. However, other relatively common complications from major nasal surgeries often mask ENS, meaning it is often overlooked or misdiagnosed by medical staff, particularly as it will not show up on a CT scan.

According to a paper published in 2001 co-authored by doctors from the Shijiazhuang-based Norman Bethune Medical University, 14 people were diagnosed with ENS between 1996 and 2000, all of whom had undergone various nasal surgeries, mainly turbinate resection. About half reported severe depression following their procedures.

Unfortunately, the paper attracted little attention in Chinese medical circles. In another paper published in 2011, it was stated that one out of five patients who undergo turbinate removal or resection will go on to develop ENS. The paper also advised that doctors be prudent about turbinate resection, and called for a ban on aggressive surgical measures, such as laser treatment, that have an enhanced risk of causing the condition. However, aside from specialists in major urban centers, China’s overworked, underpaid medical professionals rarely pay attention to current medical research.

The doctors who dismissed Lian as a hypochondriac were among the most overworked in China – assigned to crowded cities with limited resources, many worked 13 hour shifts for less pay than the average urban office worker.

Revenge

After he was incarcerated in the psychiatric care facility, Lian began to talk openly about “taking revenge” on the doctors he felt had ruined his life. On the wall of his bedroom, the names of Wang Yunjie, the doctor who consulted him many times on his condition, and Lin Haiyong, the CT operator, were inked in bold strokes, reading “7.31 Wang Yunjie and Lin Haiyong die.” He had a picture of himself taken at a photo studio in town and gave it to his mother, telling her it would soon be all she had to remember him by.

Lian’s mother attempted to keep him confined to the house, but he managed to sneak out when she left the house to wash some clothes. 10 days had passed since her son had returned from the psychiatric care facility. He left his belongings at home, including a cell phone and all his cash, taking only enough for a one-way bus ticket to the gate of the No. 1 Hospital.

On arrival, Lian demanded to see Dr. Wang. After a brief quarrel, Lian produced a hammer and struck Wang repeatedly on the head until the handle broke off. He then began to stab Wang in the back with the knife he had concealed in the sleeve of his jacket. A doctor who attempted to come to Wang’s aid was also stabbed repeatedly.

Lian then headed to the radiology department, where he attacked Lin Haiyong, the doctor who had conducted his multiple CT scans. He attacked the staff member he found working in the radiology lab, only asking his name after he had stabbed his victim three times. It was then he discovered that the man wasn’t Lin, but another doctor named Jiang Xiaoyong. On learning of his mistake, Lian hesitated, giving Jiang the chance to seize his knife. It was only then that hospital security arrived to wrestle Lian to the ground.

Wang was pronounced dead on arrival in the emergency room. Doctors waiting outside burst into tears. To their horror, however, some of the patients who had been watching the commotion, applauded when Wang’s death was announced.

 A former colleague of Wang’s, speaking anonymously, said he had no idea when he had become the enemy of his patients. He described how he often had 50 consultations every morning from 7 AM, and often had no time to use the bathroom or answer his phone. Most of his colleagues would habitually work 13 hour days simply to keep on top of their workloads.

 “I cried not just for Wang, but for us all,” he said.

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