Wednesday, February 11, 2009
this is not an easy post.
i try to be philosophical. i really do. if i'm not there worse would happen, i tell myself. but somehow i struggle to believe my own spin.
the state hospital is struggling. if i get called there it is usually in the middle of the night and i usually am not that enthusiastic about it. but if i must, then i must.
recently i was called to help with a complicated appendix. i use the word complicated, but i really mean african complicated. it was a mess worse than i can describe. suffice to say a cuban trained (the south african government send a handful of medical students to get trained in cuba) medical officer (junior doctor) was doing calls as the surgeon on call. he cut into a hapless victim without having clinically evaluated her. truth be told, i think he did evaluate her but he didn't have the clinical savvy to figure out what he was dealing with. his south african trained junior had actually made the right clinical call but was out ranked and had to concur. only when the wrong incision had been made and wrongly extended, all just after midnight, was i called to try to save what remained to be saved. fortunately i am not particularly intimidated by such surgical challenges. i dealt with what i got.
but if what i got was not enough, what i was told i truly struggled to deal with. you see, i try to be philosophical. in december when i did a thoracotomy for a gunshot wound, a procedure that is not actually supposed to be in the armamentarium of a general surgeon, all went well. later i heard second hand that the patient had died because he was transferred to another hospital because of a lack of icu beds at the local hospital. the only problem was he was transferred in a sub optimal ambulance. the short version is he died. i was devastated, but philosophical. i reasoned i had done my best and he would have died anyway if i wasn't there. i did my bit but my bit was not enough in the greater scheme of things. philosophically i try to reason with myself that in a war situation there will be casualties. there will be people who die unnecessarily. i must do all i can to prevent and limit this but it will happen none the less.
then that night, the cuban trained junior doctor who was doing calls in surgery in a setting where he in all reality could not be expected to cope, told me about another consultation he had turned away. i knew he had the habit of turning people away and because i knew he was not equipped to deal with most of what came his way i sort of understood. however the night in question i was on cover for him. there was no excuse.
he calmly informed me a peripheral hospital had phoned about a stab wound neck that was bleeding actively. the hospital in question had no surgical cover and couldn't operate such a case. he apparently refused the transfer on the grounds that the patient was bleeding. simple logic i thought would inform most people that the bleed needed to be controlled before there was any hope of survival and this could only be achieved surgically. it seems simple logic was not one of the subjects in the cuban medical curriculum. he refused the patient on the grounds that the patient was bleeding when that was the exact reason the referring doctor was seeking to refer the patient. i told the medical officer the patient would die without surgery. he cooly and calmly said in that case the patient will already be dead because they phoned six hours ago. i was shocked. even my usual philosophical outlook could not justify this. my philosophy relied on me doing my best and after that accepting the outcome based on the system. to accept the patient died because a junior doctor refused to accept a transfer because he hoped for a bit more sleep that night was just a bit too much even for my flimsy philosophy.
he maybe slept well. i did not.