An overly frustrating day

The inefficiencies of the hospital really got to me today. Well, it's really the inefficiencies of the healthcare system as a whole, reflected at MTRH.

Yesterday, we had an M&M (morbidity and mortality) conference for the pediatrics department. In America, these once- or twice- monthly meetings are used for different departments to present cases that had bad/avoidable outcomes (such as infection, prolonged stay, disability, or death), in order for the department as whole to discuss them and see what improvements can be made to avoid such outcomes in the future. So I thought it would be here, but I was wrong. For example, newborn unit presented a few-day-old infant who came in overnight basically in septic shock. The intern overnight was not able to get an IV in this baby (IVs in children tend to be very difficult), and it was not clear as to whether this intern had called for backup from the registrar or consultant. Long story short, this baby was delayed getting fluids for about 12 hours, and the infant ended up dying in about 48 hours. The lack of immediate IV fluid resuscitation was pinpointed as the critical moment in this case. Which, it probably was. But instead of discussing with everyone how this can be avoided in the future, it turned into a slam-fest, with the consultants completely lambasting the team for their "terrible" doctoring, "In my opinion, it's like this patient was never seen at all." Yes, it's all well and good to blame the intern. The ONE intern, who I might add, is in charge of both pediatric wards at night, which means seeing ALL of the patients that get admitted that day (which can be anywhere from 20-50), as well as deal with all of the patients who are crashing. And in a ward where 60% of the kids would be in the ICU in America, that's a tall order. Yes, the intern should have taken steps to get an IV in the infant, there's no question. But can we not arrive at that point without completely beating everyone down? Apparently not. The most frustrating thing about the conference was that the consultants want to get all up in arms when things go wrong, but they take absolutely NO responsiblity for anything. For example, on my particular team we're supposed to have 3 different consultants. Dr. Tran (the IU doc) rounds with us on Mondays and Wednesdays, Doc 2 on Tuesdays, and Doc 3 on Thursdays. Dr. Tran rounds with us faithfully, I've seen Doc 2 all of ONE time (She showed up for 10 minutes of rounds 2 days ago), and Doc 3 has NEVER once been to rounds. She was on the ward today, but blatantly looked at our team then turned around and walked away. So.... basically the interns and registrars end up making all of the decisions all by themselves, and you know, I really think they do the best they can. It's not like they blatantly neglect or harm patients on purpose. But without the guidance of the more experienced, how can you not expect things to go wrong??? A system that gives the most responsibility to those with the least amount of knowlege and experience is patently wrong. Yes, the interns and registrars need to LEARN, but how can they if no one is ever there to TEACH???

In America, it works as a pyramid. The Attending is in charge of all of the patients on the team, they take ultimate responsibility for what does or not get done for or to the patient. Then the upper level residents, they are in charge of about half the patients on the team, then the interns, about a third, and the medical students one or two patients each. This way, when the medical student misses 10 things that needed done for the patient, the intern will catch five of them, the upper level resident the next 3, and the attending will catch the last two. This greatly reduces patient harm, and in the process everyone LEARNS, and the next time the medical student only misses 9 things, and so on. But here, it's totally backwards. The INTERN is actually in charge of all of the patients, and the consultants apparently, put no responsibility on themselves. I'm going on and on about this, but if the healthcare system here is ever going to change, it's the CONSULTANTS who have to place it on themselves to start that change; by taking responsibility for patient outcomes and training those under them to do the same. At least that's my opinion.

Overally it is just so frustrating. Patients wait for hours before getting fluids, tests are not ordered, or are ordered but not sent, or are sent and then lost...and all the while patients are dying around us, and the consultants just seem to scratch their heads and say "how can this be?" We have one little girl who is SO sick. She came in with severe pneumonia but then got septic, and we've been treating her with antibiotics but she just keeps getting worse. So we switched to 2nd line antibiotics, and she just keeps getting worse. Well, it turns these past 7 days we've been ordering antibiotics she's not actually been GETTING them. Any of them. At all. Not even one dose. How can this happen?!?! In America the staff responsible would be immediately fired and then probably sued. (Robert says what the Kenyan medical system really needs is a bunch of US lawyers.) And this kind of thing happens every day, on every ward, to multiple patients.

I just have to realize that I'm not here to make systemic changes. If I tried I would be this unbelievably frustrated every day, and I'd burn out very quickly. All I can do is try to make a difference one patient at a time. And if I can get my patient IV fluids in 3 hours instead of 6, well then I will have to count that as a major victory.