As the axiom goes “After event even a fool is wise” and at Jodhpur’s Umaid hospital they are proving it right . For those who have missed the haunting news in National dailies , 16 women have died so far in Jodhpur Government Hospital due to administration of allegedly contaminated IV fluid; The issue has lately raised questions about state of hygiene and sanitation in hospitals .
The all time favorite blame game is in full swing. Inspection committee is calling names to doctors at Hospitals, Doctors are blaming the administrative authorities, administration is blaming lack of resources Following lines from a famous Bob Dylan song always ring in my head after such incidents.
How many ears must one man have
Before he can hear people cry ?
Yes, how many deaths, will it take till he knows
that too many people have died?
The answer is blowing in the wind......
Before he can hear people cry ?
Yes, how many deaths, will it take till he knows
that too many people have died?
The answer is blowing in the wind......
It would not be out of place to share an appeal mailed to me by a senior doctor of the subject hospital .
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DEATHS OF DELIVERED WOMEN IN UMAID HOSPITAL, JODHPUR
The treating Doctors’ perspective
THE MISHAP- What has happened in the deptt of Obstetrics ,Umaid Hospital,Jodhpur in the month of February has been a terrible accident- a very unfortunate heart rending series of incidences over which no single person or a group of people had control. It was not an act of commission or omission but seemingly the interplay of an out of the world hitherto unknown FACTOR that mercilessly snatched away so many lives.
THE DEPARTMENT- If the work culture as prevails in our department for so many years were to be responsible then this kind of deaths should have occurred in the past too. But our statistics vouch for us that similar mortalities have never been an integral part of the history of this department.Most of us have been associated with this department for more than 10-15 years and we have not seen or heard of such deaths because of PPH.
FINDINGS OF COMMITTEES- Our teaching has been faulted, our training has been criticised, our devotion to work and duty has been challenged, our integrity questioned and our department has been cursed. Eyebrows have been raised on each and every act of ours. They came with a purpose and they have been able to achieve it. Our students are ignorant fools, training is faulty and non- existent, work culture is pathetic, sanitation is abysmal and we do not give any TIME to the department. We were held directly responsible for a chocked gutter or a faulty window. It appears that the mountain like figures of upwards of 70 deliveries per day are being handled by inept students and untrained nurses.
The falling standards of medical teaching and learning in medical colleges is not an ailment confined to our department, the reasons for this are many, the debate is a long one and surely has nothing to do with the present RUN OF MORTALITY in our operation theatres that is being investigated.
ACTUALITY- Our statistics do not speak this way. Mortality figures from our institution compare well with others. Our OPD attendance is rapidly going up and we are facing an unprecedented rush in our ANC clinic, Labour rooms and our OT’S are panting for breath.
Private practice- Doing private practices outside hospital hours in our residential chambers is not a nefarious activity, a shoddy doing or a crime. We only render our services to the citizens of this city strictly in accordance with the rules and regulations that govern the state medical college teachers and in a way we work almost double than our Delhi counterparts.
THE EXPECTATIONS- Instead of experts coming to our rescue trying to help us find the culprit in the environment, that evasive superbug, that puzzling factor we only have a host of higher ups descending upon us making us parade in front of them like hard core criminals only to hear that you are shoddy, faulty in your basics and that everything is wrong with you and your work and you deserve the gallows.
WE AS WE ARE- This is not helping anybody. Our morale is shaken, our confidence battered, our self esteem lost and our hand tremble when we operate or conduct a procedure.
OUR PRAYER- We collectively mourn these deaths, we are as shaken as the kiths and kins of the deceased. Why the Almighty chose our hands for these unfortunate deaths we fail to understand. But our image has been tarnished and we deserve a little more than mere brickbats for our years of service to the Suncity.
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The question here is not that who is solely responsible for the incident ? The questions are : Doesn't someone get the salary for ensuring the quality of drugs administered, ? Is someone paid from exchequer's money for ensuring proper sanitation and hygiene ? If not then, how everything comes in order and becomes spic and span on day of some minister's visit ?If everything about the hospital, staff and doctors is shoddy and out of place then what were these inspecting authorities doing, besides waiting for things to go wrong ?
I am no one to blame anyone with my limited intellect ,but I as a concerned citizen surely want to ask or tell few things to every doctor who is reading this .
Someday go to the emergency of your hospital and silently watch how nonchalant and easy going residents and doctors at duty are. Please tell them that the causality brought there is someone's father , someone' husband and world of few might be revolving around that person .For you he is just another patient . Please try to understand the condition of people and at least pretend concern and appear sympathetic.
If you know things are lousy and below acceptable standards why don't you refuse to carry on? Time is ripe for us to decide whether hands of few semi educated politicians or your brains runs these hospitals.
Well, these committees and reports are just time buying tactics and part of the procedure to bury the hatchet .Rest assured we the common people will forget about such episodes and get busy with more important world cup of cricket sooner than you realize.
Only if I could , I will give a copy of Murphy's law to every government official and frame and put these lines of Hellen keller on every officer's desk
When I first heard of this news, it really bothered me, especially since even in my city the condition of the government hospitals is pathetic.
ReplyDeleteWhat bothered me more, was the lack of media attention. The major national english channels just did away with a scroll update. At least I did not see any major channel following that story. May be I missed it, don't know.Perhaps other issues, Egypt, Libya, Japan getting more attention.
but somehow whenever i see some endless war of words among the same old spokespersons of political parties aired on various channels, I feel they instead could have pursued a relevant issue. We all know how those political debates end. Why not focus on something useful,and nothing gets them worked up like media attention does. People may condemn "media-trials", but then what other effective form of accountability exists?? Not even RTI
Passing the buck remains the order of the day in almost every institution.Frustrating.
@Shinny , I agree that the media at national level has not taken up the issue in detail may be because it has happened in a smaller city.
ReplyDeleteThe core problem is "chalta hai" , Aisa hi hota hai" "Main kya kar sakta hoon" have become part of our psyche . I always say this to everyone who is pursuing MBA that management is not about a degree it is an attitude and a way of life.
Most of the managers believe that there job is to catch people doing wrong things and then admonish and punish them, where as, the real job of manager is to identify the strengths of people and groom them . Good management is about having the vision to analyze the things that can wrong and take proper corrective measure rather than crying over the split milk. There are so many things about health sector that can be improved but I think only Incidences overcome inertia.
I think our upbringing peculiarly honors the act of blaming, and takes it as indicator of intellect.
From some of the mails I received it appears that the word "Blame Game" is being misinterpreted.
ReplyDeleteThe teams coming from center are putting the whole blame on the doctors which is not fair and is demotivating for local doctors . The effort should be on cleansing the system and not on bullying and fault finding.
A police officer was burn alive by mob in another city of Rajasthan two days ago . Doctors are manhandled by hooligans at hospitals after every death . As suggested by me in post " Time is ripe for us to decide whether hands of few semi educated politicians or your brains runs these hospitals". Day is not far when the mind of society will tell these politicians to run hospitals , power plants and administration.You see hands agitating and going on strike everyday think about the scene when brain goes on strike.......Remember who is John Galt?
Sunil,
ReplyDeleteThanks for bringing me to this post!
First of all, let me tell you I am no expert in infectious diseases, nor in obstetrics and gynecology. Nor have I seen any death because of post-partum hemorrhage. In fact, I've been sort of lucky to have seen very few deaths in my hitherto short career despite having done my internship in a very busy charitable hospital. Moreover, my experience in the medical field is quite less indeed.
My comment will be largely on two prongs - the technicalities of the current case and the status of (State-sponsored) health care in India.
1.
I must say that the data provided in the newspapers is very insufficient to draw any logical conclusions.
I am surprised that the hospital and state authorities reached this automatic conclusion that the deaths were because of firstly some infectious agent (bacteria/virus) and secondly that they were because of infected IV fluids.
There can be many causes of postpartum hemorrhage (PPH) [bleeding from the uterus following delivery]. One that prominently comes to my mind is retained placenta or 'membranes'.
Out of 16 deaths, it seems three had also involved still-births. Now picture this: usually in government hospitals like these, pregnant women do not get admitted before hand to deliver, unless and until they would have 'booked' a bed in anticipation of some emergencies/complications. If the lady is delivering for the first time, her hospital stay before the delivery is typically not of more than 4 to 5 hours. If she would have already had a child before things proceed much faster and the stay prior to that of delivery is typically not of more than 2 hours. Which means even if IV fluids would have been started immediately upon entry into the hospital, it is unlikely that in that much time infection would have set in, crossed the placenta as well and caused a still birth. Of course, it is possible that gram negative bacterial infection would set in, cause gram negative septicemia ('infection of the blood' resulting in altered function of blood components, lowered blood pressure, high fever, etc.), a bleeding disorder and thus severe hypotension (low blood pressure) and because of which the fetus would die (resulting in still birth). But to be honest, all this happening in such a short span of time (few hours) seems implausible. A person with greater knowledge of gram negative septicemia would be in a better position to address that issue....
...Also, there was a mention of a particular deceased patient having undergone cessarean section. Usually in government hospitals, cessarean sections would not be performed without some indication (reason) for doing the same. This fact raises the likelihood that she (Prem Kanwar) was not a 'perfectly normal' patient. Maybe something (infection) had already complicated her pregnancy?
ReplyDeleteAnd if I remember it right PPH can be primary - immediately following delivery (vaginal as well as cessarean section) and secondary - that is, within a week of delivery following an uneventful delivery (blood loss-wise). So, unless and until we know whether PPH cases were primary or secondary it become even more difficult to comment upon anything.
Now even if we assume that the cause of postpartum hemorrhages was some infection, what was the source? That is very difficult to answer.
It could be anything - infected gloves/suturing needles/suture material used for delivery as well for suturing of episiotomy (and incision placed on the posterior part of vagina to enlarge the diameter of vaginal outlet to facilitate the delivery of the head), then, infected needles for establishing IV lines, infected tubing, or even simply not swabbing the skin with spirit before inserting the IV catheter. IV fluid itself getting infected is sort of unlikely except for if a 'vent' (needle inserted into the plastic 'vial' to avoid development of negative pressure) would have allowed for the entry of bacteria (or less likely, virus).
I guess, before reaching the conclusion that the cause of PPH was indeed infectious patients' blood culture and PCR (if available) must be done to ascertain the presence of some infectious agent in the blood stream. The two ToI articles you linked make no reference to any autopsy findings.
Also, the article mentions that some of the IV fluid vials did turn up positive for presence of bacterial contamination. Important question is: were these used vials or fresh ones? If they were used vials then the result hardly has any sifnificance at all, because the vials can get contaminated even after the infusion gets over! Moreover, as I pointed out infection is more likely to occur because of contamination of needles or IV catheters. If they were fresh vials with no breach in the continuity of the container, then the onus largely falls on the manufacturer; hospital would have no liability at all in whatever happened. Because manufacturers of IV fluids are responsible for quality control of their product. Norms for IV fluids are particularly stringent, because these have to directly enter the blood stream, making it very easy for any infectious agent to gain entry. Also, was the same strain of bacterium/virus that had turned up positive from vials also present in the blood stream of the patients who died or suffered from some illness?...
...Were there also some patients who suffered from PPH, but did not die? Because as one of the doctors' rightly pointed out, merely contamination would not result in septicemia in all cases, and outcomes would depend on patients' immunity.
ReplyDeleteThe treating doctors' perspective you have published here hardly addresses any technical issues of the kind I mentioned above. But that is sort of understandable because they were in damage-control mode and ordinarily common people would not have an appetite for these kind of technicalities.
Now what actually could have been the cause of those 16 deaths in a span of 2 weeks?
It is very difficult to say. Especially, given my lack of expertise and highly insufficient data. I would not even rule out foul play by some hospital employee. Also, it is important to know whether the area that the hospital was serving had any epidemic of an infectious disorder, because of which the patients were already infected before their entry into the hospital and already suffering from septicemia?
Is it a case that any of these patients had first called a 'dai' (midwife) who attemmpted delivery and because of some complication these patients came to the hospital?
Lastly, it is important to know what was the mortality rate because of PPH in the same hospital/ward before these 16 deaths had taken place? It must be remembered that PPH is the foremost cause of death because of pregnancy in India. So, if we assume that two or three deaths were occurring in that hospital per week were happening in the hospital even before this incident, then epidemiologically speaking, 16 deaths might not be as significant as it sounds. But then the appeal by doctors indicates that indeed these deaths were clearly in excess of mortality rates because of PPH in that hospital.
So, given all of the above things, I find it a bit too premature to blame all of these deaths on contaminated IV fluid, except for if there is some vital piece of information I am not privy to.
The state of walls/windows and how the operation theater looked are mere distractions from the real issues at hand (as far as cause of death of those women is concerned) except for if all those who died had also undergone cessarean section....
...To worsen all this, many patients are not cooperative and ill-behave with the hospital staff.
ReplyDeleteOn top of all this, most of the people who enter the medical field have to face immense competition. They would have academically among the best in their school days, but after entering the field they are faced with uncertainties and cut-throat competition to earn even a basic livelihood (medical procession for youngsters is no longer as lucrative as it used to be in the past).
Added to all this is the fact that in a government set-up there is no accountability. I don't know about Rajasthan, but in many parts of the country, the nurses just don't do any work, because their jobs would be 'permanent' and except for under extraordinary circumstances they cannot be removed from their jobs. Same is the case with all the doctors who would be permanent employees. So the the above kind of antipathy coupled with the 'permanent' government-job assurance and the fact that there is no incentive (monetary or otherwise, except for 'job satisfaction') whatsoever to do excel is the reason you get to see the kind of indifference you get to see.
Are the doctors to be blamed for all of this - yes and no! Yes, because whatever be the case, they are supposed to try their best, otherwise they must not enter such a field. But "no", because I judge any person against the social milieu from which they would have emerged. Is India a country where government institutes are corrupt, lethargic, inefficient and indifferent? Are professionals in other fields any more efficient and dedicated to their work than are medical professionals? No! So, why this extraordinary expectations from just the doctors?
We obsess too much over 'ought', but forget that basic psychology is quite overbearing. A man whose brother would be babu in a government office and for which he would be respected despite his being totally useless in his position cannot be expected to become a very different kind of doctor.
I don't have too many suggestions to improve the work-culture, because India suffers from immense resource crunch because of high population density. But what can be done is that the number of MBBS and PG seats should be increased at least 10-fold. The patients must not be given so much subsidized treatment. Because when there is too much subsidization, the fact is all the related instruments and facilities are just on paper, and because of which these patients anyway have to fall back on the private sector. At least 30% of treatment cost must be recovered from the patients.
What all this would ensure is that the workload per medical professional would come down, their pays might increase, leading to lesser frustration with job, lesser antipathy and greater empathy for patients, and hopefully a better quality of care....
Thanks Ketan, for the detailed analysis and for giving the discussion a wider perspective.
ReplyDeleteThey have still not clarified as to which organism was responsible for the deaths . Indeed the sample taken was from the batch under question and were fresh and unopened.
I totally agree that media is sensationalizing the issue now as it is reporting every death which has nothing to do with the old story. No hospital in the world has key to immortality and the cases referred to Government Hospitals are mostly critical and complicated.
People agitated by media reports misbehave and act violently in Hospital which is very grave and sad.