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Shortcomings in health care
When I got this email from the former acting medical director of the San Fernando General Hospital, anaesthetist Dr Anand Chatoorgoon despite its dramatic accusatory tone, I was relieved. The silence from doctors despite an open letter and repeated calls to the General Secretary of the Medical Professionals Association of T&T to respond to the public’s utter loss of confidence in public health care following the tragic case of 29-year-old Chrystal Boodoo-Ramsoomair who died at the SFGH after a C-section was deafening. We, the people, not privy to the closed door meetings by doctors were curious to know why the medical fraternity was up in arms over the subsequent suspension of the five doctors and five nurses, the firing of the SWRHA’s CEO, and overly concerned with the ‘protocol’ of the medical probe than the death of a young mother.
We wanted answers because we knew that Ramsoomair’s death was not an aberration but a symptom of a virtually collapsed health sector. It could have happened to any of us. Since the last column, several doctors including Dr Chatoorgoon let me know that they felt persecuted by this series (which called for accountability on behalf of patients) and wanted to give their side of the story. Below, I have reproduced Dr Chatoorgoon’s (the former acting medical director of the SFGH at the time of Ramsoomair’s death) position as told to me over email and the phone as faithfully as possible.
Dr Chatoorgoon’s response to health columns:
• “In the wards when patients are lying on the floor stretching out their hands calling for help I don’t know what to say. We have overcrowding. We are begging for beds. There is a shortage of nurses. There is a shortage of doctors. The biggest shortage we have is of blood, which came about after the chit system was removed. There is a shortage of equipment, of CT scans, of BP machines. On Chrystal’s ward there was only one nurse and one BP machine for some 27 patients. All 14 departments gave strategic plans to the ministry to fix this. We were repeatedly told “we don’t have the money.”
• “We don’t speak up for patients rights because when I defended my CEO for being fired without an investigation, warned that the suspension of doctors and nurses would put pressure on the system, I was told that my contract would not be renewed.”
• “From the very beginning, we stated that we had no objections to an enquiry.
However, we felt it was unwarranted, unnecessary, unjust, unfair and uncalled for, to suspend the doctors and nurses, to fire the CEO and to refuse to renew the contract of the medical director all at one fell swoop without a complete and comprehensive report.”
• “Patients in need of elective surgeries were not operated on, not because of the doctors “go slow” but because of the refusal of the CMO and the PS to clarify a statement that doctors without postgraduate degrees cannot act as registrars, which was eventually clarified by the PM herself who confirmed that doctors without postgraduate degrees can act as registrars.”
• “There is a complaints procedure for the South-West Regional Authority. When a complaint is made, reports are sought from all the relevant persons by the Quality Department which then puts together a comprehensive report. The CEO then convenes a meeting with all involved to discuss the findings of the report with a view to making the necessary recommendations to address identified weaknesses and or deficiencies/failures in the system or to address shortcomings in the performance of the healthcare personnel).”
In the case of 29-year-old Chrystal Boodoo-Ramsoomair:
1 “Admittedly there was a delay in picking up the fact that Chrystal was bleeding inside her belly on the post-operative ward because of the paucity of nurses on that shift. So the nurse was not monitoring the vital signs as she should have been doing for at least four hours for a high risk post-operative Caesarean Section. But when it was discovered that Chrystal was bleeding, I can say without any fear of contradiction, and as God is my witness, that all attempts were valiantly made to save this young girl’s life. The entire anaesthetic and surgical teams were on site to give the best they could give. They moved with speed and swiftly arranged to have Chrystal in the operating theatre to find out why she was bleeding. Chrystal died in the ICU with all the relevant doctors and nurses around her as they all watched helplessly as her vital signs fell sharply.
2 “The diagnosis of DIC (Disseminated Intravascular Coagulopathy) was entertained prior to the hysterectomy in the reception area of the operating suite by the consultant anaesthetist who was with Chyrstal during and after the hysterectomy. This condition which can occur following delivery is associated with bleeding everywhere and can sometimes be difficult to control in spite of blood components which Chrystal did receive.
3 “Prof Vijay Naraynsingh spoke with me about this case using a term called ‘reactionary haemorrhage’ for which he said no surgeon should be held responsible. All a surgeon can do at the time of closing an abdomen is to ensure that the operating field is dry which was done. But, vessels can open up in the post-operative period due to a variety of factors such as coughing, straining, turning, pushing, vomiting, retching.
4 “I have reservations about the reported issue of ‘two bleeding arteries’ alleged to have been seen at the post-mortem at which I was present. Bleeding arteries in the face of a normal blood pressure would spurt like two fountains such that it couldn’t possibly be missed by two qualified surgeons, scrub nurses and consultant anaesthetist. This would easily be seen by all present, none of whom would have allowed the surgeon to close the belly in such a scenario.
5 “Finally, doctors are not uncaring, uncompassionate, unkind individuals Ira. We were all devastated by Chrystal’s death and in my respectful view, the doctors and nurses all really tried to save this young girl’s life. But alas, no matter how hard we try, patients will die because there are so many unknown variables and unexpected factors in the equation but we do the best we can within the limitations of the system in which we practice, within the limitations of our own knowledge, within the limitations of our own experiences. ” Having heard both sides of the story from so many of you, doctors and patients, I am forced to conclude the following:
There is a disconnect between the Ministry of Health and the health professionals. The medical fraternity is under pressure, forced to watch helplessly as health care collapses around them. The medical fraternity is silent on the subject of the shockingly high incidence of heart disease, diabetes, hypertension and cancer (and is not working with the ministry to create awareness); silent on your patents rights and doctors Code of Ethics absent from their walls; silent on the question of doctors simultaneously working in the public and private sector; silent on the need for a data bank to check the track record of doctors; silent on the need for continuing medical certification; on the need for a medical ombudsman; silent on why, despite so many publicised cases of malpractice hardly anyone has been struck off the list; on why doctors rarely testify against one another and block for one another in cases of negligence.
Perhaps Ramsoomair’s death wasn’t in vain. We’re are more aware, more wary. Doctors need to start talking to the Ministry of Health and the people of this country openly about the problems so it can be sorted out. Citizens need to take more responsibility for our health, to eat right, to exercise, to educate ourselves. If we fail to reach out to one another, to heal, our collapsing health system, with its disgruntled doctors, poorly equipped hospitals, shortage of nurses and blood may just roll over and die on us.
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