The country is currently convulsed by the deaths that have taken place at the dialysis centre in Souillac Hospital. To date, a total of 11 patients have died, and all were Covid positive. Most patients undergo long-term dialysis for kidney failure, for which there are many causes, diabetes and hypertension being two of the main ones in Mauritius, in addition to cardiac disease as well as chronic infection or stones in the kidneys. Kidney disease itself may lead to complications such as anemia, heart disease, bone disease, gastric problems, etc.
Covid-related deaths. Pic – sciencemag.org
Over and above these conditions, these patients, the elderly in particular, may also have other medical conditions such as cancer which complicate matters for them. One must not also forget the medications that they are taking, which have their own side effects. Altogether, therefore, in addition to the main cause that has led to the kidney failure, there may be one or more other medical conditions (e.g. cancer) that are present, and all these are what are called co-morbidities. The result is that a patient who is undergoing dialysis is already in a compromised and weakened state of health.
Nevertheless, many patients in kidney failure have been leading more or less normal lives while undergoing regular dialysis for years altogether. The cause for concern at the moment is that so many of them have died in such a short time as they became infected with Covid. Clearly, it has precipitated their deaths, but this raises two issues:
To what extent is Covid solely responsible? Could there be other factors in their overall management that can be identified?
How and where did they get infected with Covid?
According to the statement made by the Minister of Health in Parliament, an independent enquiry has been set up at the level of the Medical Council to look into the matter, and whether there has been any medical negligence.
While this is in order, equally if not more important is for the health personnel (medical and nursing) to carry out their own analysis of the events, and review all the aspects of the management during this time of crisis and overload of work with its own burden of both mental and physical stress.
This is the only way to identify any gaps in what could be called the ‘supply chain’ of procedures and services that provision of the dialysis service entails, of medical, nursing, and general nature such as cleaning of the area, attending to non-medical needs of patients and so on. In principle this should lead to an updating of the existing protocols with a view to be better prepared for the future: for all the information that is reaching us from all over the world is that Covid is going to be around for a long time more, and we definitely need to keep that in view.
As regards the onset of infection in these patients, it goes without saying that the conditions in quarantine centres – including hygiene and food supply –, as well as transport to and from the Souillac Hospital must be thoroughly scrutinized.
However, there is one major factor which concerns dialysis centres: the quality of the air present in them. It is now established that the main mode of spread of Covid is by aerosols in the air. Both infected staff and patients can therefore transmit the virus, and this will be facilitated in the presence of fans and aircon equipment, which will only be recirculating infected air.
The way to prevent this is to have laminar air flow systems in these centres, and no dialysis centre in Mauritius currently has such a system. It is recommended for operation theatres also, and again our OTs are not equipped with laminar air flow systems. This is an issue which concerns the health system and its institutions which must be addressed with the degree of urgency that it demands if we are to avert further cascades of Covid-related deaths at the dialysis centres. In the interim, the experts concerned should advise on how to curb potential Covid infections there.
It can be seen, therefore, that it will be premature to jump to any conclusion of medical negligence when there may be institutional lacunae also that must be taken into consideration, as to whether they can add up to being a form of contributory ‘institutional negligence’.
This is also of concern with respect to the unfortunate case of the death during delivery of the pre-term baby at the SSRN Hospital. This is not the place to go into any detailed discussion of the case, but there is a major and critical problem as regards our maternity services. That is the total absence of any formal, accredited training for midwives.
There was a programme in the past for a one-year training for midwives, and for those who qualified and were posted to the maternity services to be properly renumerated. Unfortunately, this programme has been abandoned. Unless it is reinstated and the conditions of service of midwives be reviewed, by recognizing their special competencies, it should not surprise if such mishaps recur.
When we were junior doctors, it is midwives who taught us how to conduct deliveries. Hats off to them, but they are no more. The country needs properly trained and adequately remunerated midwives.
A last point of equal importance relates to communication and support. In a lecture that was delivered in London many years ago (the Rock Carling Foundation Lectures), it was pointed out that nearly 50% of problems that arise in medicine are because of poor communication – at all levels: between senior doctors and junior doctors, doctors and nurses and the latter among themselves, and between health staff and patients and/or their relatives/ responsible parties.
And the more difficulty that is anticipated in any given case, as the one under reference for example, the greater the need for communication and dialogue, and being ready to respond to the anxieties of the patients, but also to be frank about what can or cannot be done, so that there are no undue expectations on the part of patients or relatives. In this regard, it is senior medical and nursing staff who must mentor their juniors, and also the nursing staff so that there is a coherence in the approach.
So much for the ‘technical’ aspect. But patients and their responsible parties also need psychological support and counseling in their moments of difficulty, and sadly, this is a neglected aspect of medical care in our health system. This is a particularly felt need in the public sector with its overload and the complexities of the healthcare-lay interface. This need too must be addressed, and we have enough general and clinical psychologists who can be roped in at such times of crisis to provide counseling and support.
The problem in this country is that we do not effectively use the range of our existing professional strengths. We would be so much of a better service if we were to do so, and thereby avoid the kind of untold and avoidable suffering that is an indictment for all of us.
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