THEATRES OF DEATH

At the end of that night when young Chrystal Boodoo-Ramsoomair may have bled to death at the San Fernando General Hospital (SFGH), the top medical administrator ended his day: “we lost another one”. Chrystal must surely have meant everything to her children and doting husband, but on this night she became “another one”. And in the hands of inadequate hospital administration and divided doctors any of us can be yet “another one”.

Weeks after Chrystal’s death Senator Rolph Balgobin cut straight to the point: why and how did Chrystal bleed to death in one of the country’s major medical facilities?

Those two questions may not be answered satisfactorily in the series of investigations around Chrystal’s death: litigation will definitely resolve them. There is a three-member ministerial committee investigating the firing of the CEO and a three-member panel investigating the events of the night Crystal died. Neither of them is likely to expose the significant weaknesses in healthcare and if they come anywhere close to doing that, then the words “Gafoor Heath Sector Inquiry” should be familiar. Expect nothing and you shall not be disappointed.

Inadequate hospital administration and a few doctors divided—on paid public time — between public and private work, weaken the country’s healthcare. Every time a supervising doctor walks away from a public bedside and heads to the well appointed beds of private facilities, public healthcare is seconds from disaster. Even experienced doctors can make fatal mistakes and absence is one such mistake. In that absence public healthcare facilities become theatres of death.

Of course it is all part of the doctor-divide, the fundamental right of doctors to work in public and private health care, an opportunity born out of scarcity of resources and demand for medical services, in which doctors double up for duty in both the public and private sector. The danger comes when a few supervising doctors do the two simultaneously and religiously and weak healthcare administrators look away.

Consider this case. By the time Dr William Johnston, an obstetrician and gynaecologist, was delivering Cassidy Ediger in 1998 in a procedure deemed high-risk at a Canadian hospital, he had done more than 15,000 deliveries. His attempt at a rotational mid-level forceps procedure to assist delivery went wrong and Cassidy was deprived of oxygen. By the time Cassidy was delivered by C-Section 18 minutes later, she had suffered severe and permanent brain damage. In 2009 the British Columbia Supreme Court awarded an 11-year-old Cassidy $3.2 million. But Cassidy is non-verbal, tube-fed, wheelchair-bound and entirely dependent on others for all her needs. In just a few minutes the very experienced Dr Johnston got it wrong. Why wouldn’t an unsupervised and inexperienced doctor also get it wrong?

From all accounts Chrystal’s team of doctors had more than a few minutes and from her private doctor’s account his specialist services were available but refused. The troublesome thing about Chrystal’s case is that it seems to lack complexity. For a few days Chrystal’s death might have been complicated by the political and industrial relations actions around it, but at the heart, it remained a matter of inexplicable medical negligence. Patients do not usually bleed to death in the care of a team of doctors—the direct result of arteries severed and left so.

Chrystal’s death and the litigation which should follow will also resolve some other things. Now it is accepted in medical malpractice that to breach a recommendation of a professional guideline does not of itself constitute a failure to meet the applicable standard of care, so that adherence or non-adherence to the Ministry of Health guidelines is not necessarily a controlling factor in this case. But one of the matters to be resolved is whether we ought to distinguish between a qualified, skilled and experienced specialist and a medical practitioner who is allowed under Ministry guidelines to perform specialist duties but is not professionally qualified to be appointed to that specialist position.

There is inconsistency coming from the Ministry on exactly what is its policy and even a current advertisement on the Ministry’s website for a Registrar at the Eastern RHA asks for specialised experience or “any equivalent combination of experience and training”; there is no request for specialist qualification. So that a fundamental question for healthcare administrators is whether they heighten risk by using administrative fiat to stick bare medical practitioners with specialist duties, responsibilities, obligations and expectations for which they have not been qualified by the traditional overseas bodies.

Then in determining issues of negligence and liability, healthcare standards and standard of care will be relevant but just as relevant will be the practices at the SFGH and the resources available to medical professionals. The questions will include the standard of care expected of the medical practitioners managing Chrystal; the actual practice at the SFGH at the time; whether the doctors/nurses as a group or individually failed to observe that standard and did the loss of Chrystal result from any failure?

Of course the law recognises that you cannot impose or expect an untenable standard of care which the hospital and professional resources could not have tolerated. There is a story of one doctor, eight months pregnant, having to come out to offer support to a depleted shift: what other administrative nightmares haunt SFGH?

There are also the troubling questions of the unexplained urgency; the consultation; what opportunities were immediately available for support; was support requested; was support available; what is the practice at SFGH regarding support; how standard is this practice; and what variations occur across institutions? In all of this the public must have ongoing concerns: what higher risks obtain across institutions; what studies have been done across institutions; where are the findings; what should the public know; and what risk is the public taking in health care without knowing?

And the most important question: with inadequate health care administration and senior doctors divided between private and public healthcare, where are the country’s theatres of death? After all who wants to be “another one”?

Extracted From: Trinidad Express Newspaper

Published on Apr 5, 2011