Monday, March 14, 2011

Uncertain : They are as ever


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......

It would not be out of place  to share an appeal mailed to me by a senior doctor of the subject hospital .
.........................................................................

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.
.................................................................................................
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

I am only one,

but still I am one.

I cannot do everything, 

but still I can do something; 

and because I cannot do everything,

I will not refuse to do something 

that .....I can do

11 comments:

  1. 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.

    What 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.

    ReplyDelete
  2. @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.

    The 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.

    ReplyDelete
  3. From some of the mails I received it appears that the word "Blame Game" is being misinterpreted.
    The 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?

    ReplyDelete
  4. Sunil,

    Thanks 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....

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  5. ...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?

    And 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?...

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  6. ...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.

    The 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....

    ReplyDelete
  7. ...2.

    Coming to the larger issues of quality of State-sponsored health care, there are too many things I would like to state:

    a. There is a lot to be desired.

    b. Who carries the 'blame' for the poor state of health care? I think blame has to be collective. In my understanding, the biggest flaw is socialistic thinking and policy. I might be biased in this regard (socialism - something that I so very much hate), so I suggest a pinch of salt in what I have to state. :)

    Our collective mentality has become too licensing-oriented. Meaning, we tend to think that anything that gets a license is 'fit' and anything that does not get a license is 'unfit'. This thinking would not be flawed if the process that leads to licensing itself would be foolproof. And when I say licensing, I mean it in very generic sense (applicable even outside of medical field). The purpose of license in India is not so much to ensure that the quality of goods/services provided would be good, but to maintain a certain kind of 'exclusivity'.

    I case of medical field, this licensing occurs at largely two levels: hospitals and the services they are allowed to provide and the individuals (doctors, nurses, technicians, etc.) who actually come in contact with the patients. The licensing procedure in case of latter is competition-based, in the sense, a 'fixed number of people' get a license, and whereas the 'benchmark' for gaining that license is not fixed. Meaning, e.g., every year approximately 50,000 people enter the MBBS course. It can be safely assumed that at least 35,000 of these would get into some kind of practice later on. Which means that irrespective of whether those 35,000 people were above or below 'par', they would get to practice. I am not even getting to the process that leads to the selection these 50,000 class 12 students who go on to become a doctor. This process has absolutely nothing to do with testing of ability/temperament required to become a treating doctor/surgeon/paramedical person. Moreover, it is also possible that out of some 50,00,000 lakh students who 'wanted' to become doctor, and of which 4,50,000 who did not get 'selected' would have actually become better doctors, but they did not get selected, because our criterion for selection was wrong and also because we are obsessed with numbers rather than with standards.

    So basically, this situation creates a paucity of health care providers. And though we feel that the 'bar' for entry into the medical field needs to be high, all we are actually ensuring is that the number of heatlh care providers be 'less' and not that their quality be 'high'. This gives rise to monopoly of sorts. And because of which there is lesser competition among doctors (at least in the remote rural areas). On the other hand, in State-sponsored health facilities, there is immense human resource crunch. I read somewhere that in a day 70 deliveries are conducted. Belive me, that is a very high number. In many colleges in the first year of postgraduation (junior residency), students work for more than 20 hours a day, 365 days a year.

    Apart from the fact that this kind of exhaustion makes one careless and prone to committing errors, there is a far more profound consequence - this creates in minds of budding health care providers a strong antipathy towards the patients. A patient is seen as an enemy, an obstacle in path of sound of undisturbed sleep, a proper meal, even to relieve one self of 'natural pressures'. Moreover, with so much morbidity and mortality around, one gets used to it. It is very difficult to lose sight of the fact that one who we are dealing with is a human, is dependent on us and we need to try to do our best....

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  8. ...To worsen all this, many patients are not cooperative and ill-behave with the hospital staff.

    On 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....

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  9. ...c. Sometimes patients (actually, their circumstances) are also to be blamed for these kind of events. Even today the proportion of deliveries conducted by untrained 'dai' is very high. Obviously, these midwives are untrained and do not take proper sanitary precautions. Also, the status of women is so poor that they are only treated as child-producing machines. In my hospitals I have seen cases wherein the woman's inlaws would make the pregnant woman work in hot Sun in the field right till the expected date of delivery! No wonder, many of these used to have intruterine deaths.

    Bad nutrition (increasing chances of infections) and lack of spacing between pregnancies (makes it difficult for uterus to contract, thus bleeding is difficult to stop) increases chances of events like PPH. Also, many patients arrive at the hospital absolutely at the last moment, which makes it difficult to arrange for beds, medical staff to look after them, blood for transfusion, etc. Plus, the fear of contracting HIV, Hepatitis C/B, when the patients would not have the required test results makes medical professionals a bit wary of taking risks.

    d. Lack of facilities like working autoclaves (which would result in excessively tight packing of linen and thus inefficient destructin of bacteria and spores), unavailability of IV catheters, syringes and even gloves. Many places still use gloves that are not discarded after use and are reused. One can imagine what would happen if they are not boiled properly.

    e. Too frequent deliveries leave little to time to clean the surface over which deliveries are carried out. One of the residents from a Mumbai hospital had told me that in a day a sinlge resident on a single table would conduct 30 deliveries, and many times just after a patient would deliver, the next patient would be made to lie down on the same unclean table with blood from the previous patient still remaining on it. And this they would have to do because otherwise the next patient would deliver on the floor itself!

    I think most of the above things can be only gradually improved when India's population density would come down and India gets out of the socialistic mindset.

    However, I must add that I have no idea of the work culture and conditions at the Hopital in question and what I have written here are my experiences from working in Maharashtra.

    Lastly, you might find this heart-breaking story of Ignaz Semmelweis (click) very enlightening with regard to the human nature, the only connection of which with current discussion is deaths following delivery.

    Am sorry for this much long comment, but I would not have done justice had I left out anything. :)

    ReplyDelete
  10. Following should have been between third and fourth parts above:

    ...2.

    Coming to the larger issues of quality of State-sponsored health care, there are too many things I would like to state:

    a. There is a lot to be desired.

    b. Who carries the 'blame' for the poor state of health care? I think blame has to be collective. In my understanding, the biggest flaw is socialistic thinking and policy. I might be biased in this regard (socialism - something that I so very much hate), so I suggest a pinch of salt in what I have to state. :)

    Our collective mentality has become too licensing-oriented. Meaning, we tend to think that anything that gets a license is 'fit' and anything that does not get a license is 'unfit'. This thinking would not be flawed if the process that leads to licensing itself would be foolproof. And when I say licensing, I mean it in very generic sense (applicable even outside of medical field). The purpose of license in India is not so much to ensure that the quality of goods/services provided would be good, but to maintain a certain kind of 'exclusivity'.

    I case of medical field, this licensing occurs at largely two levels: hospitals and the services they are allowed to provide and the individuals (doctors, nurses, technicians, etc.) who actually come in contact with the patients. The licensing procedure in case of latter is competition-based, in the sense, a 'fixed number of people' get a license, and whereas the 'benchmark' for gaining that license is not fixed. Meaning, e.g., every year approximately 50,000 people enter the MBBS course. It can be safely assumed that at least 35,000 of these would get into some kind of practice later on. Which means that irrespective of whether those 35,000 people were above or below 'par', they would get to practice. I am not even getting to the process that leads to the selection these 50,000 class 12 students who go on to become a doctor. This process has absolutely nothing to do with testing of ability/temperament required to become a treating doctor/surgeon/paramedical person. Moreover, it is also possible that out of some 50,00,000 lakh students who 'wanted' to become doctor, and of which 4,50,000 who did not get 'selected' would have actually become better doctors, but they did not get selected, because our criterion for selection was wrong and also because we are obsessed with numbers rather than with standards.

    So basically, this situation creates a paucity of health care providers. And though we feel that the 'bar' for entry into the medical field needs to be high, all we are actually ensuring is that the number of heatlh care providers be 'less' and not that their quality be 'high'. This gives rise to monopoly of sorts. And because of which there is lesser competition among doctors (at least in the remote rural areas). On the other hand, in State-sponsored health facilities, there is immense human resource crunch. I read somewhere that in a day 70 deliveries are conducted. Belive me, that is a very high number. In many colleges in the first year of postgraduation (junior residency), students work for more than 20 hours a day, 365 days a year.

    Apart from the fact that this kind of exhaustion makes one careless and prone to committing errors, there is a far more profound consequence - this creates in minds of budding health care providers a strong antipathy towards the patients. A patient is seen as an enemy, an obstacle in path of sound of undisturbed sleep, a proper meal, even to relieve one self of 'natural pressures'. Moreover, with so much morbidity and mortality around, one gets used to it. It is very difficult to lose sight of the fact that one who we are dealing with is a human, is dependent on us and we need to try to do our best....

    ReplyDelete
  11. Thanks Ketan, for the detailed analysis and for giving the discussion a wider perspective.
    They 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.

    ReplyDelete

Your viewpoint will definitely give it wider perspective

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