First do no harm

First do no harm

1st/ 2nd September 2011: The last few days have been quite frustrating from a medical perspective. I knew when I came here that the quality of medical care wouldn't be anywhere near as good as it is in England due to lack of resources, but I don't think I had considered the impact that possibly poorer medical education of the doctors, nurses and midwives would have on the quality of care. I'm not sure all of the mistakes I have seen in the last few days can even be accounted for by inferior education (possibly - I’m assuming so due the country being a lot poorer and so having less money available to train doctors) though; some of them seemed to be due to just poor judgment and arrogance/ laziness on the part of some of the doctors. I don't like to be so harsh but I really have seen some shocking clinical practice in the last couple of days.

Will have to split these mistakes up I think or this post will be farrrr to long. :S. So starting with Thursday morning:

Thursday morning we were all due to watch an exploratory laparotomy on the patient mentioned yesterday who had a bowel obstruction. This was meant to be happening first thing and by about 9.30am the patient was ready and lying in the operating theatre. So far so good.

Unfortunately for the patient before the operation could start, another patient was rushed in to the other major operating theatre for an emergency c section because the patient had taken local herbs (this seems v.v common) and they were worried about fetal distress. Apparently there were not enough staff available to fill 2 operating theatres today because it was a public holiday. This meant the patient had to wait lying on the operating theatre for was almost another 2 hours whilst they performed the caesarean. Not ideal, in England public holiday or not, enough healthcare staff have to be available to safely run the hospital and this is what you sign up for when you train in a healthcare field. Still I don't blame the staff for this, this just how the system is arranged here. Also obviously the emergency patient had to take priority, but what I don't understand is why the staff left the poor patient just lying in the theatre waiting for two hours when there was a room just opposite with sofas etc which surely would have been more comfortable and less frightening for the patient. When the operation finally did start the patients BP was very very high (210/160 ish) even though it had been on normal range when she was on the ward. The anesthetist even said that maybe this was because she had been kept waiting in theatre so long, so they obviously do understand here the effect that fear can have on patients general conditions so I don’t understand why they had not taken just a little bit of time to make sure she was more comfortable. As it was, the operating theatre she had to lie in was connected to the operating theatre that was in use by an open doorway listening to the operation going on which I imagine must have been terrifying! Still this wasn’t a life threatening aspect of clinical care, so it wasn’t this in itself that really annoyed me. Side note, we also watched the c-section and when the baby came out she was not breathing, the other medics resuscitated her and she was breathing but not very well and not properly crying when she was taken from them to go to the warm baby room, here there were no staff to observe her condition and the baby was going to be left completely on her own there if the students hadn’t decided to stay and look after her until the family arrived to take over.

It was what occurred during the operation that scared/frustrated me. When the patient was opened up it was clear just how obstructed she was – her bowels were so filled with air that they literally looked like balloons. Firstly the doctor thought the bowel obstruction was caused by adhesions which are a common cause of obstruction (although are usually caused by past surgery which this patient hadn’t had) so she removed these and compressed the bowels to try and deflate them. They didn’t deflate so rather than thinking that there must still be an obstruction somewhere further down which realistically must have been the case or the bowels would have deflated on compression, the doctor decided to puncture the bowel and deflate the bowels that way and then close up the patient because the adhesions were gone… Mistake number 1 and 2. I’m pretty sure that puncturing the bowel is something that you are meant to avoid at all costs due to the infection it would most likely cause and even if I’m not right about this (AJ and I both think we remember this from our G.I surgery placements but that was a while ago)the logic of assuming you have fixed the problem when the distension cannot be pushed down the bowel (when closed!) and out is very very odd. I don’t think I’m explaining the scenario very well, but basically if the bowl is still distended then there must be distension still further along the bowel and the doctor hadn’t even checked for this before assuming everything was ok and she was going to close the patient up. It was only because we asked well why is the large bowel still distended (it was the small bowel she had punctured and emptied) that she decided to look closer at that bowel and then said she had found a mass below the sigmoid colon. However she was still just going to close the patient up and refer her to see the specialist who was visiting in about 1months time... Again I get that they don't have the resources to do that much here and there are things they cannot treat but without some kind of treatment the patient would just obstruct again and so the surgery and the pain associated with it would be for nothing. I think the surgeon noticed our shocked faces at this because she asked us what we thought she should do. We asked if they were able to perform colostomys (where part of the bowel is brought through the skin of the abdomen and opened out so can be attached to a stoma bag and stool will pass out of this opening into the bag, rather than through the rectum - so an area of blockage in the bowel beyond the stoma can be bypassed and so bowel obstruction prevented) at the mission hospital, she said they could and after deliberating eventually called the doctor on the team who specialised in colostomys.

By the time the colostomy specialist had arrived the patient had been on the table for quite a long time. During this time (and at times during both the first and second part of the operation) the patient’s blood pressure dropped dramatically several times and it was obvious she need more fluid to compensate for the blood loss caused by the operation and a couple of times the patient would either move or grimace in pain indicating the anaesthetic was wearing off. Whilst there was an anaesthetist in the room, he seemed to pay very little attention to how the patient was doing and was not very good at checking these signs. Several times AJ and I had to go tell him that either the BP seemed very low or the patient was moving (he was frequently standing at the window looking out rather than observing the patient) and only then would he give her either more fluid or more anaesthetic. Mistake number 3 :S.

The colostomy didn’t happen in the end because they could no longer feel the mass they felt before and decided it had just been a kink in the catheter, they removed some more fistulas they found lower down but the bowel remained distended. At this point they decided to do a PR examination (feeling in the rectum with a gloved finger – not nice but necessary) to check there wasn’t a mass or something in the rectum. I can’t believe they hadn’t done this before doing a full exploratory laparotomy!!! In England all junior doctors are taught that if you don’t put your finger in it you put your foot in it – in other words potentially this very scenario, don’t open up the abdomen if there’s potentially something that could have been fixed without doing so in the rectum. They didn’t however find anything on this occasion, but that for me doesn’t change the fact that they could of and that the patient could have been going through all this pain for nothing, also the original doctor very arrogantly stated that “It's not a doctors job” which annoyed me no end. It might not be a job that we enjoy doing, but it is checking the patient’s health so it IS a doctor’s job. In the end they closed up the patient whilst her bowel still looked very distended declaring that fistulas were the cause, regrettably I don’t imagine she will have a great outcome but I really really hope I am wrong.