7 May 2013

For those who refuse to see

First of all, I want to apologise for the length of this post, quoting two recent articles I’ve read in the news. It will take some time to wade through, but I urge readers to pay attention and stick to it… the impact of the articles are profound.

Second, due to personal circumstances, I am still under a gag order of sorts, which forbid me to comment on health issues (only) in TnT. That does not mean I am not outraged and willing to accept the status quo.

Third, (and this affects me directly) the health care system in TnT is so appalling in certain circumstances (read those last 2 words again) that I have been advised not to return to TnT to live since my heart attack. This advice came from people within the health care system, and bolstered my own opinion which is as a result of observations, inside information, and my own experience working in the health sector in TnT.

But on to the two articles:

Emergencies at public health institutions in this country are generally prioritised by gunshot wounds, stab wounds or arriving in an unconscious state.

Those whose illnesses are not as visible, regardless of how ill they may feel, are told their cases are not emergencies and so inevitably they are left to wait for hours on end to get medical attention.

The Express witnessed this torture that hundreds of sick people of different ages and genders were forced to endure at the casualty areas and clinics during visits last week to the Eric Williams Medical Sciences Complex, Mt Hope, the Port of Spain General Hospital and the Arima Health Facility.

At all three medical institutions, members of the public voiced concerns that death would probably knock at their doors before they were seen by the doctors.

However, the process at the Arima facility was by far the worst as the sick were forced to move no less than five times to five different rooms at the institution before they could be seen by a doctor to be diagnosed.

One woman at the Arima Health Facility, who was among more than 100 people waiting in the General Practitioner area, told the Express she was weakened after three days of vomiting, pain and frequent bowel movements and had gone to the Arima facility, dreading what she knew would be a slow and painful process.

With no other alternative, she arrived at 8 a.m. where she was greeted by scores of people who lined the corridors, seating area and walls of the waiting area.

Her wait to be seen by a doctor was even longer than she dreaded and, by 11.45 a.m., now barely able to sit up in her chair she said, “You could have time dead inside here before you see a doctor. Look at the time and I still sit down here waiting and if you see how much people in the other rooms still waiting.”

Walking along the corridors of the Arima Health Facility, entering the various treatment areas was a shocking experience as scores of visibly sick people seeking medical attention waited. Women with babies in arms, toddlers, pre-schoolers and teenagers. Elderly people all were forced to wait, some for close to five hours before they could be seen by a doctor.

Malcolm Jack, who also arrived at the facility a little after 8 a.m., said although there are times the wait is not as long, that day was overbearing.

“Is now two and a half hours that I here and I haven’t seen anyone yet. I think the problem is the number of people who working here because they have just one person registering you in front and is already a hundred and something people here already for the morning,” he said.

At noon Jack was still at the hospital.

An elderly woman, who had also been waiting for quite some time was overjoyed to hear her name called to go into the doctor’s office, jumped off her seat and shouted “Praise the Lord!” as she made her way across the room.

As people waited in various areas of the facility, many fell asleep sick and exhausted by the long wait.

Christina Sealy came with her 64-year-old mother to have a dressing on her foot changed.

“We have been here since a little after eight, it is already 10.45 a.m.

We have number 126, they are now at number 111 and we haven’t been screened yet, plus they have to take blood and all that, so is whole day,” she said.

Jennifer Rogers, who attends clinic there, said there is a serious need for a real hospital with more staff to care for the people of Arima.

“Here never have medicine. They give you the prescription and when you go to the dispensary you can’t get the drugs. A while back I was sick so bad I could not even walk. They prescribed something for me, but they didn’t have it here so I had to go to Sangre Grande to get it.

People does never get medicine here; is either they don’t have it or the dispensary closed.

“Because it come like your family need food and you close off the kitchen. Sometimes people have to go quite to Mt Hope to get the prescription filled and before they get there they die,” Rogers said.

Another patient described the process as tedious. “Here is like a big oversize clinic because if you have a real emergency they have to send you to another hospital. The fastest area you are seen is in the front when you are given your number,” she said.

The horror stories the Express found at the Port of Spain General were of a similar nature, but had complexities of their own.

Imagine having a medical condition since 2004, not being able to afford private health care you go to the public hospital hoping to not only get some relief for your condition but also to have it diagnosed and eight years later after being transferred from one clinic to the next there is still no diagnosis for your medical condition.

This is the story of a 40-year-old mother of four from Diego Martin who has been transferred from the care of one doctor to another in at least four different clinics at the same hospital over the past eight years but none have been able to diagnosis what her complaint is.

According to the woman, who asked that her name not be used, she was at the hospital for an appointment that she was given in 2010 to hopefully this time get a diagnosis for the problem she has lived with since 2004.

“I started getting a bad pain on my right side but it would go and come, but whenever I over-worked I would get it, so I came to the hospital. They took X-rays, MRIs but so far they have not been able to diagnose what is wrong with me.”

“When I got the appointment back in 2010 for 2013 I told the person who gave me the appointment that I could have time die before I get diagnosed because of the length of time I had to wait,” she said.

Having to wait hours in the clinic at the Port of Spain General Hospital, she said, was painful in its own way.

“This system really backward yes. You come here early, you come late, you still leaving late because is who you know.”

She said she has had to endure the torture that the system metes out because she is poor and can’t afford to pay to be seen at a private institution.

The clinics which were at one time in separate locations are now in one area, so on any given day people in the eye clinic, surgical clinic and orthopaedic clinic all have to assemble in the same area to wait, which makes it confusing for people because they have no idea who came before them to see the same doctor.

The Express bumped into Germaine Henry, a 64-year-old woman from Carenage, who told her story of being turned away by nurses after being given an appointment to do a procedure for numbness in her feet after she and a nurse had a quarrel at the Carenage clinic.

Henry said she continues to suffer because of this.

“I went to the clinic because I wasn’t feeling well, but I got there a bit late, about 9 a.m. because of the pain and numbness in my right leg it takes me longer to get dressed and to walk.

“So when I got to the health centre, I met a young lady who had also just arrived and I asked her whether there were any more cards to see the doctor. She told me that the nurse told her to sit down and wait. I told myself that if she was being allowed to see the doctor the nurse would also allow me to see him— this never happened.”

Henry said she asked the nurse if she would be allowed to see the doctor and her response was discourteous. But Henry said she waited anyway, hoping that the doctor would see her.

“I sat there waiting and when the last person came out the doctor came out of the office and called me by name. I found it strange because the nurse had not given me a card to see him but I said yes.

He then told me that he would not be able to see me that day and that I would have to come back another day.”

She said she left and subsequently got an appointment at the Port of Spain General Hospital for the procedure to be done, but the same thing happened again.

Henry said she ended up getting another appointment for the procedure to be done at the Port of Spain General Hospital and the same thing happened again.

“Two people who came after me were called in before me; but I sat there waiting because I could not believe that they would do that again, because I had to stay 24 hours without eating in order to have the procedure done.

“A good while later the nurse called me by name and told me that she had bad news that they would not be able to do the procedure.”

She said she went back to the doctor who had referred her to the Port of Spain General Hospital and told him what happened.

“The next time I went to the clinic the nurse called me again by name and asked me who had been talking to the doctor about what had happened. I told her that I did because I found it to be an injustice.

Little did I know that it was the same nurse who I had the first falling out with who had been transferred back to the General Hospital and had me going in circles. I am a sick elderly person and you preventing me from getting the health care I need out of spite,” she said.

At another clinic at the Port of Spain General, a patient waiting to be seen in another clinic told the Express a story of long waits but this time added in another element of lost files.

Asked her thoughts on the current system at the Port of Spain General Hospital, she laughed and said, “Same old story— the system is poor. When you come here you have to wait so long. Yesterday I was here for another clinic appointment and I spent almost whole day, so this morning I didn’t rush myself.”

She said the administration at the hospital is terrible.

“I don’t know if they are bombarded by the amount of people they have to care for but they lose your files and have you sitting waiting and won’t tell you what’s happening and you seeing people who come after you going in front of you. You give them all of the information possible hoping for a smooth process, but they don’t write down the information and then you end up in these frustrating positions.”

She said there needs to be the introduction of a number system at the Port of Spain hospital, which the Mt Hope Hospital currently operates under.

“Not everyone has the luxury of being able to stay away from work in order to get health care. People have jobs and they can’t spend all day waiting to see the doctor; they have to go back to work.

Loss of files was also an issue that the Express picked up on at Mt Hope.

An elderly patient who had cataracts removed two weeks ago was told to return to the Eric Williams Medical Sciences Complex, Mt Hope, for a follow-up he got there at 6 a.m. but up to 11.45 a.m was still waiting to be seen because his file could not be found.

One woman who came all the way from Manzanilla with her husband on two consecutive days also had complaints about the administrative staff at the hospital.

“They need to be more organised because they were constantly making mistakes that are avoidable. We came here yesterday because my husband had to do an ECG but the girl who gave my husband the appointment wrote down the wrong date.

“It was supposed to be today but she wrote down yesterday’s date when the person who is supposed to do the ECG is not there on Wednesdays so we had to come back today. And that happened because she was talking so much instead of concentrating on what she was doing,” the woman said.

Asked whether she, too, has problems with accessing medication at the pharmacy, she said it takes too long so her husband purchases it outside.

Several women waiting for their spouses to be seen at various clinics or to see the doctors themselves all complained of not being able to access medication at the pharmacy at Mt Hope.

http://www.trinidadexpress.com/news/Long-long-wait-at-hospitals-206215251.html

Have you begun to feel outrage yet? Still straddling that hypothetical fence? Read on:

The country’s first sextuplets should have been delivered overseas to ensure they got the care they needed. That was the recommendation of local and overseas specialists. And as baby Persia Meleigh Lee Foon-Cummings, the fifth-born of the sextuplets, battles with pneumonia, serious questions are being asked as to why the warnings of consultant/head of the Neonatal Intensive Care Unit (NICU), Dr Camanee Lutchman, were ignored.

Two of the baby’s brothers, Kaelon Nasir and Paeton Christopher, both died from upper gastro-intestinal bleeding weeks after parents Petra Lee Foon and Kieron Cummings welcomed the bundles of joy into the world. The other three babies are said to be in satisfactory condition. In January, Lutchman warned hospital authorities that the lives of the sextuplets would be at risk if they were delivered at the Mt Hope Women’s Hospital (MHWH).

After their birth on March 4, chairman of the North Central Regional Health Authority (NCRHA), Shehenaz Mohammed, and the medical team, led by Prof Bharath Bassaw, consultant obstetrician and gynaecologist, were elated. But the babies’ illnesses and subsequent complications should have been foreseen, in Lutchman’s view.

On January 9, Lutchman wrote to the hospital’s medical chief of staff, Dr Esau Joseph, expressing concern about the lack of equipment, space, trained nurses and senior medical staff to cope with such a high-risk delivery. She repeated her earlier recommendation that the mother should be flown abroad for management of the pregnancy and births.

The T&T Guardian understands that the expectant parents were advised by medical sources at the MHWH about the risk involved. The warning followed an earlier letter that Lutchman had sent to deputy medical chief of staff Dr Andy Bhagwandass on December 28, in which she expressed concern that she had been left out of the preparations until then, only two months before the birth.

“I was not involved in the planning of this high-risk delivery since admission of the patient to our ante-natal ward,” she wrote. “I am still awaiting a formal referral from the primary caregivers, the obstetric unit, so that I may proceed with counselling the expectant mother about the risk involved. “My first recommendation is to transfer this patient to an international high-risk maternal and foetal facility.”

Contacted yesterday, Lutchman confirmed she recommended international care was best suited for the patient. “I advised the patient of my recommendation. I had a meeting with all stakeholders and advised what needed to be put in place. I advised the patient of my recommendation. “When she decided to continue, I made recommendation for everything to be put in place. Even though there is a chronic shortage, personnel was arranged and we had the support.

“Delivery was only the beginning of the process. We now need to deal with the complications. The complications are expected, even though the delivery went well but the work just started,” Lutchman said. Commenting yesterday, Mohammed confirmed that Lutchman had expressed concern over the delivery of the sextuplets. “We were advised that we did not have everything to deal with the delivery and we did everything possible to facilitate the births,” Mohammed told the T&T Guardian.

“We met with all the team players and we were able to come together to get everything in place for this delivery. “I am informed that the complications are common with the birth of prematurity. The average survival rate of sextuplets is four out of six. Sextuplets is somethings that obstetrics frown upon because it is a risk. These babies that survived are at risk. “It is not a pretty situation by any means. It is a very complex situation.”

Mohammed said baby Persia Meleigh was removed from the ventilator yesterday. In response to a text message yesterday asking why arrangements were not made for Lee Foon to receive international care as recommended, Health Minister Fuad Khan said: “We were equipped and the NCRHA put everything in place to produce excellence in NICU.”

In her advice to colleagues, Lutchman warned: “The birth department/operating theatre at MHWH lacks the appropriate infrastructure to facilitate favourable outcomes of this extremely high-risk pregnancy.

“The NICU at MHWH also lacks the basic space and infrastructure requirements and basic equipment to accommodate and manage six extremely low birth weight (ELBW) premature infants delivered within a very short time. International best practice requires that this pregnancy be managed by a high-risk joint care team, comprising an obstetrician and peri/neonatologist.”

Lutchman also said no neonatologist was employed at the NCRHA, adding: “There is also a chronic and dire shortage of registered nurses assigned to the NICU and only a small percentage of these are NICU-trained. “These high-risk infants, while in the NICU, will require one-to-one nursing which we are unable to provide with our present cohort of patients.

“Given the above limitations, I continue to strongly recommend international intra-uterine transfer of Ms Lee Foon in an attempt to obtain the best maternal and infant outcome of this pregnancy. Despite my reservations, however, we continue to prepare the NICU for delivery.” A report on the equipment and staff required in the birth department/operating theatre was attached to the letter.

Lutchman’s concerns were also echoed by Dr Marlon Timothy, a clinical fellow of the perinatal and neonatal medicine department at the University of Toronto. In an e-mail to Bhagwandass, dated December 10, Timothy wrote: “If here in Toronto we are stretched thin for a quadruplet delivery at the number one referral centre for neonates in Toronto, I shudder to think what will happen with a sextuplet delivery that is not properly planned or prepared for.

“Earlier this year the NICU at the MHWH had one working laryngoscope. Six babies require intubation, surfactant therapy, ventilation, central lines, incubators and cannot be left to chance or poorly planned.”  He said since he became aware of the case when Lee Foon was 11 weeks pregnant, he had been trying to get the mother flown abroad for either foetal reduction or high-risk care but the cost appeared to be a problem and he had no response from the local authorities.

“This case has the potential to highlight the skill, preparation and management of the NICU but also can be a disaster with all six babies dying. “Nothing leads to greater disaster than egotistical behaviour and lack of communication,” Timothy warned.

Medical risks

Lutchman warned that premature birth was very likely with multiple pregnancies, especially in the case of the sextuplets, which increased their risk of illness or death. Lutchman also sent a two-page list of major complications that might arise before, during and after the birth of the sextuplets. Among them were:


• Intrauterine growth restriction.

• Intrauterine or neonatal demise (death).

• Nervous system problems, such as brain injury caused by lack of oxygen; seizures and  brain haemorrhages; meningitis.

• Heart problems, such as cardiac failure.

Lung issues such as respiratory distress requiring a ventilator, which might in turn lead to pneumonia; chronic lung disease

Possible long-term complications in surviving babies include:

• Mental retardation.

• Hearing or visual impairment.

• Learning disabilities.

• Gross developmental delay.

• Seizures.

• Cerebral palsy.

http://www.guardian.co.tt/news/2013-05-07/doctors-forewarned-about-sextuplets-care 

Dr Marlon Timothy, a clinical fellow of the perinatal and neonatal medicine department at the University of Toronto has hit the nail on the head even without living here: “egotistical behaviour and lack of communication”.

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