The gross Casualty Medical Officer.

Friday, March 28, 2008

A complaint that seems to be going unheard:

I am a 34 year old man from Ga. Gemanafushi living and working in Male' for the past many years. I have been to IGMH several times over the past many years to get treatment for my 15 year old daughter who suffers from epilepsy.
In all my experiences I have never come across the kind of experience as I did last week (MMW notes: email originally send to MMW in February). I was at IGMH to show my daughter because she had started to complain of headache that morning. She was saying that it was similar to the kind of headaches that she gets just before she gets a fit.

We were unable to get an appointment for Dr Ali Latheef, whom we regularly consult. Not wanting to wait till my daughter suffers another terrible fit, I took her to the emergency room to have her seen and if possible get some treatment that might prevent her from getting a fit again. She was already on medications, but we were close to running out of her tablets.

After waiting in the casualty waiting area, our token number finally flashed on the display at the "casualty medical officer" room. We had no idea who we were about to see. We wouldn't have anyway expected to see anything like what we saw. Medical treatment aside, this was a terrible sight.
Sitting almost fully slumped in her chair was a lady doctor who seemed to be in her late 20s to early 30s. She was clearly not a Maldivian. She is darked skinned, not that her skin colour bothers me (
MMW notes: we believe this description is given for the sake of identifying the doctor). Her hair was all over the place, I could have sworn that her hair had not been touched by a comb or brush in ages. Her white doctors' coat, if you would still call it white, was all crumpled, with patches of what appeared to be coffee or tea stain, the hem dirty from dust and other grime and carrying blue ink marks as if she had been drawing on it. This was THE most unsightly doctor I had ever seen in my entire life. The only things that I saw about her that gave me a hit of her having prepared to come to work were the conspicuous white talcum powder covering her forehead and cheeks and the lip-stick on her mouth.

Her spectacles, I don't know if she could really see though them, had what appeared to me as heavy oily finger prints all over the lenses.

Her appearance was so gross that my daughter turned to me and said that she'd rather see someone else. But we had no choice.
After a few questions and plenty of time to illegibly scribble on the prescription pad, and an in between happy chatting phone call in some foreign language, she handed us a treatment plan; which was actually a refill of our old prescription. She hadn't laid a finger on my daughter, who was obviously relieved that she wasn't touched by the "gross doc".

I tried to politely ask her what her diagnosis of the current headache was. In a quick but thankfully forcefully assuring tone she said "nothing to worry". I was worried. I have seen doctors see my daughter before. This was nothing even close to the minimum examination
we we used to before.
Unhappy, I went to the ER coordinator, who happened to be a senior Maldivian nurse to complain. She was nice to me. She listened to what I had to say. I complained about 2 things. Her dress sense and hygiene, which I told the coordinator was shameful for a doctor and about the way she was treating patients without examining them.
What the coordinator candidly revealed to us was not surprising: similar complaints have been reported about the same doctor on several occasions. She has apparently been talked to about the complaints by ER coordinators and supervisors. But, even after repeated complaint there has been no improvement in her attire or medical practice AND no action at all from the hospital administration either.
Determined to do something about it, I got myself excused from work the next morning to go to the CEOs office to meet Dr Yasir or Dr Fathmath Didi to officially complain. I now realize it was all a waste of time. After waiting for 2 hours I was told that Dr Yasir was unable to meet me today because he was busy with some other work. I saw him sitting in his office all this time all alone. I was given 10 minutes with one of the administrative boys who politely listened to my complaints but said that they couldn't do anything themselves. I was asked to come again tomorrow and that Dr Yasir might be able to meet me then.
Frustrated, I asked the young administrative officer to relay my complaints to his seniors as I was not in a position to stay away from work another day.

I did write a letter to IGMH the next day. Till today I am awaiting a response.

By the way, after leaving hospital after seeing the "gross doc" we went to see Dr Ali Latheef at his private practice. He was kind enough to see my daughter and change treatment.

Abdul Samad (not real name).

This email has been shortened for clarity.

Update:The case of the baby who almost bled to death from a central line.

Finally some good news!

The baby and its twin are both doing well and are expected to leave hospital in the next week or two. According to our sources the child remained in intensive care for 3 weeks because of small size and the "accidental bleeding" episode.

According to family sources the doctors looking after the children are confident that both would survive with minimal to no adverse effects. The child who had the "accident" would apparently be on anti-epilepsy medications for a few more weeks and be subjected to frequent developmental assessments to identify possible neurological and developmental deficits.

Note: We have received emails from one individual claiming to be a nurse looking after the child. Her primary concern was that we were only covering negative aspects of hospital care, in particular newborn intensive care. We would like to publicly state that we do investigate other cases as well but do not get the same level of information and cooperation from patient families when the reported cases involve adults and elderly. We are willing to bring out both sides of any story and would encourage everyone to write to us to express their views.

Food poisoning at IGMH update

Tuesday, March 11, 2008

The catering was in fact provided by Buru Catering Services. This has been confirmed to us by staff at the catering service. We apologize to Brothers Catering for having mentioned their name in our previous post.

Most of the doctors who were admitted for IV fluids have been discharged home now and only 2 are reportedly still getting treatment at IGMH. They are also expected to improve and leave for home by late evening today.

A source within Maldives Food and Drug Authority, speaking on condition of anonymity has confirmed that food samples have been received at their lab and that tests are underway. A rice preparation, a chocolate flavoured desert pudding and a beef preparation are reportedly the most likely to be the offending food. She told us that the tests are likely to take 24 to 48 hours to reveal full results.

The matter was apparently brought to their attention by Dr Ashraf himself, Buru Catering and some doctors from IGMH who were themselves affected.

Several doctors at IGMH fall sick, few admitted for treatment and several OPDs cancelled

In an apparent food poisoning caused by eating food at a party held at IGMH, several Maldivian and Foreign doctors working at IGMH have fallen sick today.

Several doctors, more than 20 according to information received from IGMH public relations counter, were absent from work today due to diarrhea, abdominal pains and high grade fever. We have received reports that a few of the doctors were admitted temporarily in the emergency room with severe dehydration and abdominal cramps last night and this morning.

Today morning several OPD clinics at IGMH were canceled because doctors could not report to work because of ill health. According to our sources, more than 15 OPDs were canceled in total this morning and afternoon. The OPD services were grounded to a halt and several patients had to return home when the hospital administration were unable to find well enough doctors to replace those who had called in sick. According to some counts some 250 appointments were canceled today. Several OPDs are expected to be cancelled tomorrow as well.

One doctor, who was herself affected, answered an SMS from us to report that the doctors ate at a party thrown by Dr Ahmed Ashraf Ali, Urologist, to mark the birth of his child (and his 2nd marriage) yesterday. She said that she thought that the food was either improperly cooked or contaminated.

The catering for the event according to another source was Brothers Catering and the alleged offending food was a rice preparation which unfortunately was a great hit at the party. We cannot confirm whether that information is correct. It was reported to us that Dr Ashraf has personally called most of those affected and offered his apologies. We hope that concerned authorities would investigate this incident appropriately.

We at MMW express our best wishes to all doctors for a full and quick recovery and hope that they are all able to return to work as soon as possible.

Baby dies at IGMH operating theater following birth by C-section.

Thursday, March 6, 2008

A baby delivered by a preplanned C-section at IGMH has today died inside the operating theater. According to our sources within IGMH operating room, the baby was delivered in a pre-planned "elective" C section at around 8:30 am on 6th March 2008. The pediatrician on "on-call" duty, a recently joined senior pediatrician from India Dr Bhagwat failed to attend the delivery despite being informed on time by Obstetric surgeon (because of Thick Meconeum in Amniotic fluid, a name given to situation where baby passes stools inside the womb).

The most junior level medical officer was asked to attend the potentially troublesome delivery and the unthinkable happened.

The baby was extracted without any difficulty according to our source, who claims that the obstetric team completed the section "by the book" because of recent negative publicity it had received in the media. She says that she and others in the room clearly heard the baby "cry" after birth. Baby was then handed over to the junior doctor (who was in place of the pediatrician). The baby apparently suddenly stopped breathing while his mouth was being cleared of meconeum by the junior doctor.

Our source reports that at this stage Dr Bhagwat was called again to attend urgently. She says that the junior doctor attempted to revive the baby and was later assisted by the anesthesia doctor in the resuscitation because of the time the pediatrician was taking in attending. The baby's heart stopped beating a few minutes after birth, just as the pediatrician arrived in the operating room.

We were told by our source that the pediatrician asked his junior to stop attempting to revive the baby and to "declare him dead", reportedly about 20 minutes after baby was delivered. He had made no significant contribution to the resuscitation effort. This had apparently created some friction between the pediatrician and the anesthesia doctor.

The family was called about 45 minutes after the baby died and told that the baby died because of "congenital anomalies incompatible with life". Family was told that the "best efforts" at reviving the child had been unsuccessful. As evidence of the anomalies, the family was shown a "dark skinned area" on the shin!

We at MMW would like to know why the senior pediatrician, who wan "on-call" for any pediatric and newborn emergency for the day, had not attended the delivery despite being asked to be present? Was he informed on time? Why was the most junior medical graduate in the department allowed to attend high-risk deliveries on his own? Was the baby alive at birth? What made the baby's heart stop (was it something that the junior doctor unknowingly did)? Could the baby have been revived had there been senior level pediatric doctors? Was the child congenitally abnormal? If not why was the family explained in those terms?

There are many many questions.

MMW is deeply concerned about the state of affairs at IGMH and call on the hospital administration to make good on their responsibilities and deliver us a safe and efficient hospital service.

Case of Gentamicin ototoxicity due to over dose? the case from Thinadhoo Regional Hospital

A 3 year old girl from G. Dh Thinadhoo has turned deaf following treatment for a middle ear infection at Thinadhoo Regional Hospital. The child was seen by Pediatrician stationed at TRH Dr Pavel and diagnosed as a case of Otitis Media (infection of the middle ear cavity).

Family member reported to MMW that child was prescribed antibiotics including Gentamicin. Gentamicin is a drug that is commonly used for significant infections caused by Gram Negative Bacteria (a special group of infection causing bacteria that are known to cause middle ear infections). Child also reportedly had 2 surgeries performed on her ear in 3 days.

During treatment parents reported noticing that the child was not responding to sounds as she used to. Initially they discounted this to be due to the ear infection. Dr Pavel had assured the family that the hearing would improve following treatment.

With the infection completely cleared child continued to have difficulty hearing. Parents were worried and had the child taken to Male' for further medical care. ENT specialist Dr Mauroof from IGMH reportedly told parents that the deafness was permanent and that it was caused by Gentamicin (which is known to have ototoxic side effects) being used in inappropriately high doses. The child has since then been taken abroad and deafness (sensorineural hearing loss due to ototoxic injury from Gentamicin overdose) confirmed.

We consulted a Maldivian pediatrician, who wished not to be named, at his clinic who confirmed that Gentamicin is known to cause ototoxic deafness in a few patients who are prescribed it. The senior pediatrician also told us that he believed that the dose used was too high. [We counter checked the dose from BNF and found that the dose was in fact unusually high. She was prescribed 80mg three times a day. This is significantly higher than the recommended dose for the 16 kg girl. The recommended total daily dose is 7.5mg/kg/day, this would be a total daily dose of 120 mg not 240mg that was given].

The pediatrician said to us that he thought that the medicine could have been an acceptable choice, but was used inappropriately. He also noted that warning signs of ototoxicity were ignored and treatment continued while the child was having significant warning signs. He also suspects that the double surgery could also have contributed to the deafness.

We at MMW understand that Gentamicin is a commonly used and useful antibiotic that has probably saved millions of lives worldwide. The ototoxic deafness caused by it is not very common, but is described even in the most basic pharmacology texts. We believe that ototoxicity may have been caused even if the correct dose was used (this is described in Gentamicin prescribing information sheets) but fail to understand why such a large dose was used and why the treatment was continued even when toxicity was noted. Did the doctor not know the dosage? Was this an error in calculating or writing? If an error, why was it not detected by nursing staff? Why were the warning signs ignored?

A useful medicine has been brought to disrepute in this case. It is however, not the medicine that is to blame. Caution is advised in using the medicine in patients with kidney diseases and hearing impairment AND warnings issued about its continued use when toxic signs are noted.

We at MMW feel that the responsibility lies with the prescribing doctor and the institution and hope that the child is compensated appropriately. She has been prescribed treatment that could help bring back hearing, the cost of such treatment should be borne by the state or the institution or doctor that was at fault.

NEWS: Attack on Dr Adil Rasheed

On 3rd of March 2008 Dr Adil Rasheed, Dermatologist at IGMH, was physically assaulted near Maafannu stadium. We strongly condemn this and other acts of violence.

A witness reported to us that Dr Adil was attacked by 2 young men (the witness suspected them to be druggies) late in the evening as he was walking on the side walk. The two men seemed to have been trying to rob Dr Adil. Dr Adil reportedly resisted and fought the assailants. In the fist fight that ensued Dr Adil was forcefully felled on to the ground. It appeared to our witness that Dr Adil fell on his right shoulder. The assailants apparently fled the scene shouting "bangalhee vageh, bangaalhee vageh" (A Bangladeshi thief, a Bangladeshi thief) when people started to gather around.

Dr Adil was helped on his feet by a by-stander. Dr Adil appeared dazed and not in his senses. Our witness reports having seen Dr Adil in similar altered-senses on several occasions before and suspects that he may have a mental illness. He was taken to IGMH in a taxi.

We can confirm that Dr Adil had significant injuries. His injuries were reported to us as fractured humerus (or a dislocated shoulder). He was discharged after treatment. He is reportedly on leave from hospital and private practice, but is expected to make a full recovery from injuries.

Once again we condemn this and other acts of violence, whether perpetrated against medical services providers or common man. We wish Dr Adil a full and rapid recovery.

Five young men die in Male' last night: Inadequate medical rescue services.

Sunday, March 2, 2008

Last night five young men died in Male following an incident at the Male Fish Market. According to news reports the five men suffocated and died when they descended into a deep "well" for some drilling work last night. It is widely speculated in the media and in rumors that they all died as a result of inhalation of toxic gases in the well.

There is a sense of disbelief in the community as to how such a terrible incident could have happened and so many lives lost in this tragic event. We would like to review the events in light of medical knowledge shared with us by our resident doctors.

Safety at work ignored
It has become apparent that safety issues related to this kind of work were ignored in the incident last night. One man after another descended into a poorly ventilated well in an attempt to rescue the people who were "fainting" once inside the well. It is reported in the media that no safety harness, ladder or other rescue/escape mechanism was in place during the preplanned work.

We realize that the detail related to this are still sketchy and that a proper review is in order to find out why safety measures were not in place. It is our belief that worker safety  is ignored in all areas of Maldivian work force. This incident highlights the need for proper planning, including worker safety review when potentially risky work is carried out.

Contacting the rescue services
It has emerged that Maldives Police Services were informed of the incident by witnesses at the site to get aid. A senior MNDF Fire and Rescue personnel complained on national TV that the "real" rescue services (them) were not contacted.

We asked some of our friends about who they would contact in a similar event. The answers we got were not surprising. Most of them said that they would contact MPS or IGMH. The MNDF Fire and Rescue services were mentioned by only one of the 25 people we contacted. This maybe a biased assessment but this highlights one issue. The general public have not been made aware of what emergency service they need to contact in which kind of incident.

This brings us to our argument for the need for a common Emergency Services. Why can't we organize an emergency response service that has teams from various fields (Fire, Rescue, Police, Medical Services) that could be contacted by calling an umbrella Emergency Service?

International practice is to have a single body responsible for Emergency services. They will be comprised of the different teams that will be mobilized to respond to an event. It would them be easier for the common people to know which number to call in an emergency. Much like the 911 service we see on Reality TV.

We also note that the information conveyed at the time of calling the rescue service is vital. If details were not provided by the caller, the person receiving the call should have the sense to keep him or her online and to gather more information till the rescue services could reach the site.

Why couldn't the rescue service reach the site?
We at MMW fail to understand why the MNDF vehicles including their ambulances (yes they do have ambulances) or the Hospital ambulances were unable to reach the site of the event. The vehicles were apparently unable to reach the area because of members of the public gathered around the site as spectators. They stopped 2 blocks away from the site. This is unacceptable.

If the president of the Maldives was to travel any road, at any time, MNDF and MPS would definitely be able to clear roads. Why was this not possible in this incident.

The public are also to blame in this case. There is always a sense of euphoria in Male' when ever something happened and the public gather as spectators. We don't understand why public should, by their own actions, prevent the rescue services from reaching the site. Was this because they were already too late? Not a reason good enough.

The response time, according to reports on national TV was about 30 minutes, far too long for any rescue service! Very slow for a place like Male'.

Why doesn't the Rescue service have medical personnel on the team?

The video footage of the victims being rushed out of the Fish Market on to ambulances (or pick-up trucks) and latter being wheeled into IGMH showed the state of our rescue services.

The victims were clearly in need of resuscitation. Sadly the video footage shown on TVM show the lack of this vital measure. No individual was giving CPR to the victims, a vital intervention that could have proved useful and even life-saving. Doesn't MNDF Fire and Rescue Service personnel have members trained in first-aid? Why wasn't anyone giving mouth to mouth breathing to the victims?

We do realize that we do not have proper medical ambulances or medical response teams, but why weren't medical teams mobilized from IGMH. IGMH has a protocol of responding to external emergencies by sending ER doctor and nurse to the site (even if  the protocol is poorly conceived and carried out at best).

If a common Emergency Service hotline was available, the person receiving the call could initiate and mobilize all these services almost instantly.

We are saddened that no person attempted CPR of any sort from the time the victims were removed from the well till they reached IGMH ER. The ambulances, even after knowing that they were responding to a life and death situation, left from IGMH with no equipment or medical personnel. Why?

The video footage shows ambulance drivers and attendants putting victims on IGMH ER beds and one doctor responding to another patient. Why weren't more doctors at the ER? In fact why weren't they or some of them waiting at the gate to receive the victim so as to initiate CPR early?

Common mans word against the MNDF and IGMH
We have seen one common man speaking on TVM saying that he was involved in reviving one patient, who he says was breathing when they reached IGMH. His words are contradicting what Dr Yasir said on TVM and what the MNDF Fire and Rescue service also revealed on TV. They both made inferences that victims were long dead before reaching IGMH.

This highlights the lack of proper medical intervention for the victims from the time of rescue till they reached IGMH. Had there been medical services or someone trained in CPR this may not have happened! We are not sure how effective the layman was in CPR, he has at least done something!

We believe this incident should be reviewed thoroughly and emergency services improved. We highlight these issue and believe these are thinking points:
  • Worker safety at all situation should be of prime importance. MNDF Fire and Rescue services could play a role in drawing up safety regulations with the Labour ministry. Especially in potentially troublesome work safety measures must be in place before hand.
  • We believe that a common Emergency Service needs to be established. This service should have an dedicated hotline (3 digit free number like 911, yes why not 911)  the number for which should be promoted by a campaign. The people manning the phone lines should be trained in extracting information from callers and if possible should have training that would enable them to advice the caller on immediate measure that could be taken. The caller then should initiate a multi-disciplinary emergency response (involving, where appropriate or in all cases Fire services, Rescue Services, Police services and Emergency Medical service). Emergency medical services should be included!
  • The rescue teams should be facilitated by the Police services in reaching the site without delay by clearing the roads. Public need to realize that impeding these services is punishable by law.
  • Until a proper Emergency Service is in place IGMH should utilize its external emergency response plan in assisting rescue missions with medical personnel and equipment. Ambulances responding to acute medical emergencies or incidents with potential acute emergencies should not leave the depot without medical personnel. Equipment should be ready for such dispatch and emergency medical officers ready and able to respond to such a need.
  • We believe that the medical response to the incident was a disaster. The lack of it is clearly evident on the video footage. IGMH, MNDF and MPS should jointly discuss the issue and identify how and who would be in-charge and running the medical services.
We also believe the families of the victims should be compensated for their loss. No amount of money would be enough, but some reasonable compensation would be useful. The employers who carried out the work should be involved in paying compensation.

Completely unrelated:
Update to newborn who nearly bled to death in Newborn ICU at IGMH: baby is doing well. She (not a he as previously reported) has come off mechanical respirator and is expected to do well.