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Emergency care: A tale of double tragedy

TRAUMA & EMERGENCY

Emergency care: A tale of double tragedy

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Emergency care of trauma patients must be prompt and effective to save lives. The slightest delay has to be avoided at all costs. But rickety ambulances on terrible roads, non-existent intensive care units, dysfunctional operating theatres and lack of trained emergency personnel are emblematic of a healthcare system as dead as the many people it kills everyday.

I’ve only been in this county referral hospital for weeks. As an intern, that sums up all my clinical experience. And this here is my initiation into emergency care of trauma patients, Kenyan style.
“That’s the mandatory deposit before ICU admission.” She says curtly. She’s about to hang up, but I press on. I am in the mood to bargain; God knows, am always in the mood when life is on the line.
“How about including it in the hospital fees at the time of discharge? Imagine they can’t raise even enough for head CT scan, this is an emergency, and he’s gasping!” My tone borders on melodramatic. It reeks of desperation.
“Doctor, you know this is hospital policy. The deposit is mandatory. we can’t change that, gasping or otherwise.” She says, hardly trying to sound remorseful. It is a well-rehearsed conversation. She’s been saying this for a while; she’s said it to me several times before.
There’s a pause.
“I am sorry.” She says with finality.
“I understand,” I say, resigned, swallowing my desperation, looking at the patient, and dreading the imminent certification of death.
“We can’t raise that amount. All our options are exhausted.” His father says. I expected that to come. It is what always happens when a family hurdles to discuss hospital fees.
“What are you going to do now?” The sister asks. That’s how they hand over the problem to you. The public healthcare system has no way of helping, the private system slaps them with high fees, the family is at the end of the tether, and the doctor has to save this man’s life somehow.
“Try XX referral; maybe they’ll have ICU space.” The nurse says.
“Are you serious? That’s several counties away. He can’t even survive a few kilometers in our rickety ambulances!” A colleague drives the point home.
This is about John, a young man just a few years older than me who was involved in a serious road accident. Nothing in his body was spared—a crashed chest with lungs soaked in blood, head pounded left and right, broken limbs and an unpromising lower back. I am inheriting him from my colleague who seriously needs to catch up on her sleep or else I’ll admit her to intensive care too!
“What did the national hospital say?” My colleague asks. She’s sleep-walking. I can tell because I had already told her that our national hospital does not have space in their ICU. But I repeat that and it seems to rouse her a little bit. Hopelessness can raise one from subconsciousness.
I understand it too well; I have been there. It’s a life we are used to.
This is a hopeless situation, indeed. This man needs intensive care and blood transfusion, neither of which this hospital has. The ICU in this hospital (one of the largest formerly provincial hospitals in the country), has been under renovation at least since I was halfway through medical school. Isn’t it amazing how much urgency is given to emergency facilities, or any facility for that matter! It’s too bad for this young man. I have been working the phones trying to find a hospital with ICU without success.
Isn’t that fantastic? What our healthcare system is? We are haggling about a person’s life, talking about deposits and everything. A patient in need of intensive care means time is of the essence, and it is incredible that the first thing that comes up is how much we have, whether we can raise a preset deposit. What we are saying when we lay such a condition is that we don’t give a damn. To hell with that life! This is, after all, a willing-buyer-willing-seller society. A man-eat-man society where we have no scruples. We have no hesitation to cash in on the desperation of fellow man.
His family leaves, dejected, expecting that they’ll be talking to the mortician tomorrow morning. I wonder what’s on the minds of those people as they leave their beloved son and sibling, their hope shattered, its pieces thrown at a novice medic who must somehow make it work out for them. Perhaps they are praying between sobs. Or maybe they are angry. Maybe they are burdened by the guilt of being so poor as not to be able to pay for their son’s life who is plummeting fast into the bottomless pit where poverty leaves all its victims. They have just joined the big pile of devastated little pitiful Kenyans.
How many families have been made to feel this way? How many parents have been left with that devastating guilt that they let their child die? That if only they had been rich, he would be alive. If only they had worked hard, if only they had inherited some riches, which means if only their parents hadn’t left them impoverished. If only they could afford the private hospital fees. If only…if only…. It’s an unending chain of if-only.
As I wonder at these things, John’s condition is deteriorating fast, his oxygen saturation plummeting terribly. Everything is stack against him. I am no specialist in intensive care or any care, yet I am his only hope. The hope of that family who no doubt are having a truly sad night. But he came here to live, not to go to someplace or other. I am here to make sure he lives, not to talk of what should have been.
So I haul these heavy oxygen cylinders to his bedside, get a heater to warm him, prop him up on the bed and fix the barely functional vital monitoring machine borrowed from another ward which seemed to be in dire need of it. It is the only one available in this ‘referral hospital’! After all the effort, we can’t get the oxygen because the key that opens the cylinder isn’t working. The nurse runs to find another one with little hope of success while I fidget with the oxygen delivery nozzle, which has seen better days. Then a call about an emergency in the other ward comes in. Another one follows, then another. It is a Friday night, after all, a time when traumatic emergencies race each other towards you. But one can only save a life at a time. This one is proving too difficult to save and too difficult to leave alone. The nurse is back, empty-handed.
I am forced to improvise. Hell, we are always forced to improvise, why even complain. Am still learning the ropes, you see, how to practice medicine out in the woodwork. Mind you, I am in a county “referral” hospital. But, anyway, the end justifies the means. I get busy. By the time things begin to work, John is unresponsive, his gasping more spaced out, his life ebbing away.
The phone rings again, and someone shouts at me from the other end. I rush to deal with several minor emergencies – some bedside stitching, another man with broken bones, a child with severe burns, another needful transfusion that won’t happen because there’s no blood in all five county hospitals nearby.
I have barely done much when he is wheeled in, this man who had his knee ripped open like the pages of a book in a motorcycle accident. This open-like-a-book knee is bleeding profusely. I apply lots of pressure dressing as I wait for the theatre to set itself. I shout at the nurse in charge to get blood from wherever. And fast. It’s never actually shouting, it’s just the language of emergency medicine. It’s the way to communicate effectively under such pressure. It’s the way of those of us on the frontlines of this life and death battle, bearing an incredible burden and working with less than the bare minimum.
I call for help, but none is available, which makes me realize its way past midnight—the you-are-on-your-own hour. I rush the patient to the theatre where we try to expand his severely diminished blood volume using intravenous fluids. His blood pressure is plummeting fast. After two hours of struggling to stop the bleeding, I realize it may be too much for one person—there were just too many bleeders for one person to deal with. The scrub nurse quits—she also hasn’t slept in a while. The patient starts to vomit. The anesthetist shouts at me to hurry the hell up. The patient settles it by collapsing! Suddenly we are all on the same team now, trying to resuscitate him. He must be taken off the operating table, immediately. The nurse in charge calls to report that a unit of blood is on its way from someplace, an hour out if the ambulance’s engine doesn’t quit! After stabilizing this patient, who miraculously seems to come back to the world of the living, I rush out to the wards.
John isn’t gasping any more, his blood pressure is not recordable, the monitor was taken away, the second oxygen cylinder has run dry, and the nurse is nowhere to be seen. I run to get more oxygen cylinders. It’s not that I have much hope. It’s because I have to do something because Hippocrates won’t let me do nothing. I rush out to deal with the other emergencies, one after the other.
The first rays of the sun pierce the horizon, startling the darkness into retreat, penetrating through the frigid cold of the night. But they do nothing to the darkness and the hopelessness of life in this hospital, nothing to the human misery that surrounds me, nothing to lighten the pain in these eyes staring at me, imploring for some intervention I know I cannot offer. I walk out of the wards to breathe the fresh air and clear my mind with the golden hue in the east. Then I remember John and sprint towards his ward!
I find him conscious; his oxygen mask off; it is as if he had never needed it. Who needs an ICU after all! His brother arrives and has difficulty coming to terms with the fact that John is alive, breathing on his own, looking around, asking for food.
“How did you do it, doc?” He asks me, like you would a magician! For a few minutes, John’s family enjoys heavenly happiness. I let them, knowing that he might collapse any minute. Nothing has solved his underlying problem.
Then John collapses again as if to prove me right.
As if on cue, my colleague arrives to take over the day shift. We work the phones together and manage to get an ICU for John. This feels like an achievement. I should be pleased. But I am not. Indeed I am sad – for him, for his family, for, well, everyone. His prospects are dim. First. The ICU is far away. Very far away. The ambulance itself is a battered, ancient specimen with no emergency supplies at all – you take a commuter van, write the name ambulance on it, install lights on it, tint the windows for dramatic effect! You put your critical patient in that thing and drive on a road which, between potholes and long sections where the tarmac is completely destroyed, is simply treacherous.
I take off my white coat and sleep-walk into the sunny outdoors, thinking to myself that medical emergencies should not insist on happening to people here if emergencies have any sense!

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