Well, this is not a story of two polyps, but the title is just so and taken from ‘Unaccountable’ by Dr Marty Makary, to pay tribute to his most authentic work done for the sake of patients and mankind, which gave me motivation to complete this article that I started drafting on a note file more than a month ago.
Disclaimer: The purpose of this article is not to promote punitive/ retributive justice, but at least to highlight the importance of right to information, transparency, impartial investigations, and to encourage a medical society that is at least inclined to learn from fatal errors (disciplinary actions to be taken where its necessary) while taking swift and efficient steps to mitigate its burden and to stop recurrence, systematically.
It was just less than one year into medical school, and we had a lecture by the then Dean of the Faculty of Medicine, Colombo and he said something interesting; “We are demigods, we have to keep that in mind” [I have not taken his permission to quote him]. This statement changed my life and my perception of medical culture forever which was already tarnished by then. It gave me a lot of things to think overnight and over-days. I spoke to some of my colleagues, some people found it arrogant and repulsive but the majority did not see it that way. I was even more shocked.
However, I moved to Singapore after clearing my final exam and it was at a time when I was on the verge of giving up my medical career. Singapore became a blessing in disguise. I learnt that a lot of text book teachings are actually possible in real life, including a lot of ethical dilemmas that I always had in mind. Truth be told, Singapore isn’t an open society. The entire political menace has encroached on routine lives of Singaporeans and transparency has become a privilege that is determined and titrated by the governance. So as Singapore Medical System, where transparency is limited and mishaps take place on a regular basis but in contrast to common Asian attitudes they take the trouble to bring defendant to justice in most occasions (not always!), which is commendable. However, Singapore Medial Council and the Court system do a tremendous job, to an extent that I feel that it is probably overly sensitive, which however deserves an applause for the progressive movement that it has represented and established over years.
Today’s topic is Sri Lanka. Its quite well-known among medicos of the region as a country that boast about a committed medical fraternity, proven track records to have the best maternal, child mortality rates and vaccination coverage (almost 100%) among all developing south Asian countries. Well, that is all true, Sri Lanka has performed really well given no pretty penny to fund this humongous healthcare system looking after over two million people. But, its important to remind ourselves that just because we have a fairly well performing health care system neither its perfect, nor the best. Contrary to popular belief of best healthcare systems, I believe that no healthcare system is perfect (or the best), every system has its own serious flaws and merits (May be someday we can create an ideal healthcare system - someday!)
Sri Lankan doctors’ society strictly follows one rule for certain; and that is ‘code of silence’, and they probably take it more seriously than hippocratic oath. I can go on for days about code of silence, but I choose not to, as its already 1.45 AM on a Friday, so I will cut to the chase.
Here are three stories from the year 2014, when my parallel batch-mates were doing their horsemanship. All three events took place at Colombo National Hospital. I am keeping these incidents anonymous mainly for two reasons: First, these cases have never been convicted and would never have any opportunity (mot-likely) to be convicted either - in the eyes of the law as all evidence has been destroyed. Second, lack of evidence could make me liable unnecessarily.
One of my ex-colleagues was covering a surgical ward as part of her horsemanship, she happened to be on-call one night and half-way through the night she decided to go home to rest. Later that night a bleeding patient was admitted directly to the ward with “HO STAT” stamp. This is when the houseman is supposed to go and see the patient within 30 minutes. Nurses tried to get through to her all night long but neither she answered the phone nor she turned up. As you may have already guessed it, the patient "bled to death". The next day morning she turned up for work as usual and by the time the consultant in-charge reached the ward she managed to miraculously jot down everything that “happened” overnight in the patient’s case notes (Bed-head ticket/ BHT). Ward consultant was well aware of the incident and his response was "just a warning" asking her 'to not to come back to his ward as a registrar'. I have no known scale to determine how wrong this sentence sounds, as well his his attitudes and perceptions.
Another day at a professorial unit, one houseman verified crossmatched (grouping and crossmatch) blood that he brought from the blood bank and started transfusion for a patient and the patient died from a transfusion reaction as a result of a ABO mismatch (as a result of wrong verification). This was a colleague from a parallel batch from another university. Final step of verification/ the final gatekeeper is the doctor in this process, of course the swiss cheese model of accident causation has taken place in this scenario but its ultimately physicians responsibility to ensure safety (this may vary from country to country depending on its training and policy) This is a punishable medical misadventure/ offence as per rules/ by-laws of Sri Lanka Medical Council (SLMC). Put punishments aside, think about having an impartial investigations and looking into the reasons why it happened, and taking corrective measures to prevent it from happening again? No! He was set free. To date there is no investigation whatsoever to the best of my knowledge.
Third story is about the colleague who was involved in the first story. Setting: vascular unit. Designation: houseman. A patient who was admitted for a kidney transplant was found to have hypokalaemia (cause is unknown to the writer) and he has been on oral replacement therapy which has been continued over days/ weeks, until he had a cardiac arrest and died of hyperkalaemia. In this case, its a collective responsibility and has to be shared by all team members as revising/ reviewing the drug chart is a responsibility of all the doctors of the vascular team on a daily basis, and not only of the houseman. And the consultant in-charge should have been held accountable and investigated thoroughly, but as per news sources no action has been taken to date.
This is just a fraction of the problem. These are just a few case scenarios from one year, of one batch of doctors, who were working in one General Hospital in Sri Lanka.
Are you astounded? Don't be!
It’s similar to common Sri Lankan attitude of ‘denial’ towards other things in life too, including war and atrocities. I don’t think I have a right to talk about war and implications of war on rural Sri Lankan life compared to someone from a bordering village or a front line soldier. It was a war against terrorism, but human rights violations in war must have been real since war doesn’t know humanity.
In short, it’s not a surprise that war crimes took place amongst all parties involved during the civil war. But how Sri Lanka was reluctant in taking the initiative of bringing justice to those who were affected and instead going into a state of denial, was well reflected in these scenarios as well. Code of silence at its best! You will never understand this until your loved ones become victims of war/ medical misadventures (I sincerely hope not!).
To be honest, this is probably not a good example and, we cannot compare war to healthcare, because there had been plenty of studies (in the US) to show that the number of people who have died as a result of medical misadventures are significantly higher than the number of war casualties over years. So healthcare in general has been much worse than all the wars in the history.
This is all about people, their lives, their right to know the truth, their right to exercise informed decision making in health, at least the right to know the real cause of death - for God's sake! Its high time Sri Lanka take ethical considerations seriously, take a stance on addressing ethical and medico-legal issues which are unfurled across sundry strata of Sri Lankan medical practice and save the sinking ship.
(Pardon all typos and syntax errors that you may find in this text - its 3.00 AM now!)
Samandika Saparamadu
25/05/2018
