Sahyadri Books Online Trivandrum.: 200. Why This Many Women Die During Pregnancy And Child Birth? P S Remesh Chandran

Tuesday, May 5, 2020

200. Why This Many Women Die During Pregnancy And Child Birth? P S Remesh Chandran

200

Why This Many Women Die During Pregnancy And Child Birth?

P. S. Remesh Chandran

Editor, Sahyadri Books & Bloom Books, Trivandrum

Image by Kevin Ramirez, Pixabay. Graphics: Adobe SP.

CROSS INFECTIONS, MEDICAL MISTAKES AND NEVER NEVER INCIDENTS TAKE THEIR LIVES

Pregnancy is a vulnerable condition with the risk of dying.

Pregnancy is a vulnerable condition in which a woman has the risk of dying. Complications may develop during pregnancy, child birth or abortion for an otherwise healthy person. Given ample treatment and care facilities exist, these complications can be cured and the woman sent away with a healthy baby. If not, both the lives of the mother and child may be lost unnecessarily. These complications arise more in poorer areas and with poorer people than urban areas with comparatively well-to-do people.

Maternal death or maternal mortality is the death of a woman during pregnancy, after pregnancy, delivery, after delivery or during or after abortion. Maternal deaths from flu are very common and nearly ten percent of such deaths could be prevented by administering flu vaccines in time. Whether cared in clinics or outside clinics, administering anti-flu vaccines is a must for pregnant women in most cases. One fourth of all maternal deaths in the world are from sepsis, and administration of antibiotics intravenously could prevent a lot of them which unfortunately is possible only in hospital-admitted cases.

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Many pregnant women die due to anesthetic errors and miscalculations which mostly happen due to anesthetists not permanently employed in a hospital but their services being called for from other hospitals on a temporary basis whose commitments may even be to their mother institutions only. Hemorrhage and loss of fluids are other common causes and neurological problems also contribute to creating untoward conditions and situations during pregnancy and child birth. Medical complications and surgical complications arising in hospitals also lead to maternal deaths in quite a number of cases.

Going to hospital with flu and returning with all the diseases in the book.

‘Went to hospital with flue and came back with AIDS’ is something we have been hearing for a long time. Cross-infection or hospital-acquired condition in general terms and nosocomial infection in medical terms is a dread of all hospitals and medical professionals. It simply means a person going to clinical settings like hospitals, clinics, nursing homes and laboratories returns home with an infection, the infection having been originated from the clinic’s environment, equipment, staff or other patients, transmitted to our woman through direct or indirect contact, air droplets or airborne vectors.

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Most people forget that a pregnant woman has to breathe, eat and drink for two people. And her body weight will be higher even while her muscles and bones remain only as strong as before. Naturally her guards will be low against acquiring infections in hospitals. She may return with new groups of bacterial and viral colonies in her inside or outside like Acinetobacter baumannii, Candida albicans, Chaga’s disease, Clostridium difficile, Enterococcus, Escherichia coli, Legionnaires' disease, Pseudomonas aeruginosa, Staphylococcus aureus, Stenotrophomonas maltophilia, Tuberculosis, or anything microbial the like. She may have contracted blood infection, gastroenteritis, pneumonia, puerperal fever or urinary tract infection while at hospital.

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The staff may have been careless and may have compromised sanitation as lain down in books and kept rooms, equipments and uniforms not sterile. They may not have subjected the rooms, equipments and their uniforms to enough chemicals, steam, heat or ionization, covering in and out and all surfaces. There may not have been used hydrogen peroxide vapor or non-flammable alcohol vapor for disinfection and surface sanitation, or ultraviolet cleaning may not have been available in that hospital for disinfecting microbial organisms which are prone to living and growing on non-living surfaces like furniture, wall fixtures, switches, knobs, buzzers, window and door openers and even protective guard rails of staircases etc., and etc., for any length of time. Their patient isolation system may not have been effective and strictly in adherence to protocols.

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Not washing the hands brings so many diseases.

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And even the patient in her weakness may have forgotten or even been reluctant to wash her hands regularly and keep herself away from sneezers and talkers. We know a number of kinds of bacterium and microorganisms are temporary or permanent residents on the human hands, human skin. Some are protective and since man has learned to live with them for ages they have become friendly and even mutually benefiting. By their presence they prevent other hostile and unfamiliar organisms from colonizing our hands and bodies, like our dog present in our compound prevents other dogs from entering our compound. These resident in-house bacteria are less pathogenic and have a very low infection rate. They are the Resident Flora of the outer layers of the surface of our skin and generally do not transmit from hospital staff’s hands to patients as they are already present in the patients’ skin surfaces too. Like the white blood corpuscles in blood they have through eons evolved as a second defensive column on the outside of the body with time. But another kind of bacterium and microorganisms colonize human hands and skin, jumping and propelling themselves to there from the environment, especially the hospital environment, and live and grow there temporarily, and they are pathogenic and have high infection rates. They are the Transient Flora of our skin. It is to get rid of these second type of invaders that the hospital staff’s as well as the patients’ hands are advised to be washed with antiseptic soaps, alcohol gels, alcohol rubs, sanitizing gels, sanitizing wipes or whatever it is prescribed and available in that hospital to prevent contamination and infection of the patient from direct contact and by touching contaminated surfaces.

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Hospital staff maintaining correct hand hygiene alone would reduce nosocomial infections by forty percent. Patients also keeping correct hand hygiene would reduce it by another forty percent as they transmitting them from part of their body like ear or neck to another part of their body like eyes or nose by touching is too natural and too common to be avoided. As so many visitors come to hospitals and they cannot in most cases keep back from touching and even kissing and stroking their loved ones lying there on the hospital beds, the rest twenty percent is unforeseen and unavoidable in the present circumstances in clinical settings unless full health education is possible for the whole human population. We can guess how many skin microorganisms would be there in the gold ornaments and watches the staff wear in spite of regulations on wearing them while on duty- a regulation the most disobeyed in hospitals. Some of them, even though they wear the mandatory hand gloves and masks, do not change them after one patient, increasing the possibility for yet another infection. This non-changing of hand gloves and masks after attending to one infected patient is also the reason why many equipments in use get infected too.

These attending staff including doctors, nurses and orderlies may not have washed their hands in alcohol rubs before and after each patient contact. Even in Intensive Care Units the percentage of doctors adhering to hand hygiene compliance mandates are as low as twenty percent to as high as only eighty five percent. It is never and nowhere a hundred percent. The same is the case with wearing gloves and masks. Or these staff may even have been careless in handling antibiotics and other antimicrobial agents in the hospital, adding risk to the patient.

Pregnant women surrounded by a microbial world of infections.

In America alone, around one hundred thousand people die each year from nosocomial infections and around two million get afflicted with them in hospitals. In England their numbers are only increasing. The mortality from nosocomial infections is better in Europe with 9000 dying in France, 7000 in Italy and 3000 in Belgium annually. Switzerland and Finland fare better than these three. Most of these are pregnant women dying and get afflicted as they are the most susceptible to nosocomial infections due to a number of conditions. In studies on labor room infections it was even proved that ‘medical student trainees were causing more infections than midwifery trainees’ as they were coming directly to the labor rooms from practical classes with cadavers.

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Catheters are one prime source for infections acquired in hospitals. To make them infection-free some hospitals use ethanol introduced into the catheter which has more possibility of causing harm through ethanol reaching the patient’s blood stream in incompetents’ hands. Over-prescription of antibiotic drugs for patients can cause antibiotic-resistant strains of bacteria to evolve. No effective drugs are available for a few of these infections and a few among these declare themselves to be drug-resistant. No known antibiotics are of any use in fighting them. And their antibiotic resistance is growing. Some of these infections may have to be neutralized through ultraviolet irradiation which creates other new problems.

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We have heard about the drug company which manufactured the mother-of-all vaccines which eliminated every bacteria and virus in the human body. It eliminated even the useful bacteria present in intestines making digestion and assimilation possible. Millenniums of man-bacteria balance of mutual friendship, familiarity, usefulness and coexistence which the human body was accustomed to since its evolution from the primeval form was toppled. The equilibrium of existence was tilted in favour of bacteria. Cancer vanished the moment this drug was administered but the patient died soon after from the invading armies of new and unfamiliar and hostile bacteria colonizing and thoroughly defeating the human body in the absence of the long-familiar friendly ones!

Would-be mothers over-prescribed and over-medicated.

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During pregnancy not a few women who otherwise are healthy are compelled to take over-medication prompted by doctors who are unsure of even themselves. Many of these doctors receive gifts (not just refrigerators or air-conditioners but cars, villas and foreign holiday flight and stay tickets) from drug companies for over-prescribing. Maternal deaths from overmedication are a more acute problem now, indicating the undue influence of drug companies over young doctors as well as veterans who all benefit from over-prescription along with those drug companies. Most of the health care professional in hospitals and those outside are put under enormous pressure to prescribe drugs and medicines wherever and whenever they can so that compliments could be unloaded to their premises by companies as part of their aggressive marketing. Proper diagnosing will leave a paper trail of crime as record behind and would prevent over-prescription. So they over-prescribe without proper diagnosing! All are pleased in this business at the risk of the patient being put to complications and harm and even death. Pregnant women and children are the most vulnerable and submissive to the treacheries of the unscrupulous trade practices of this patient care industry.

Medical errors cost the world an additional expense of 3000 billion dollars every year.

10 to 15 percent of all deaths in the world are caused by medical errors. More deaths are caused by cancer and heart diseases only. So, of all deaths in the world deaths from medical errors caused by health professionals ranks the third. And their numbers are also increasing at fearsome rates. No threat from authorities or occasional exposures by press has been able to curtail the growth in their numbers. Why it is so is because due to trade unionism, no professionals involved in medical errors ending in patient deaths could be brought to justice or dismissed from service. Let off with light warnings or even lucky to have the incidents suppressed from public notice, they continue to commit medical errors in hospitals and kill patients. It is pregnant women’s safety that is the most affected in these cases as they are the weakest and the most helpless among patients. Even more than half among them do not receive the mandatory care anywhere in the world if they do not have money. The negligence shown towards these grave offences even by the world health care organizations and their eagerness to protect their own hides is reflected well in the International Classification of Diseases having no codes for human errors.

We have heard the adage ‘never go to an old lawyer or a young doctor’; the first will have lost steam for winning cases and the second will not have enough experience for not making medical mistakes. Young lawyers are the ones who win the most number of cases and old doctors are the ones who commit the least number of medical mistakes. Human errors lead to the lion’s share of medical mistakes and system errors lead to the rest. Age and inexperience are determinants in the increase of medical mistakes. That is why the old doctor is preferable as a rule. Unfamiliarity with new medical procedures and carelessness in entering medical notations for the subordinates to read and act upon also add to this. Avoidance of market names and adhering to generic names in prescriptions was intended to bring down medical mistakes but it seems it did not.

Medical error is a term used in health care to cover up from as little mistakes as extracting the wrong teeth to as grave mistakes as administering wrong anesthetics in wrong dozes resulting in homicide. Preventable medical errors are a staggering One million in America each year and Eight hundred and Fifty thousand in England. These cause billions of dollars and pounds of additional expenses and around Two hundred thousand preventable deaths around the globe every year! How many among these hapless human beings are pregnant women and children? No accurate numbers are available with anyone. Sure, no one on the clinical or administrative side agrees alike to using the words ‘preventable’ and ‘avoidable’ in connection with people’s deaths in hospitals but they are deaths indeed, happened inside hospital walls. In their frantic move to vindicate themselves a part of the American Medical Association in 2011 even went to claim that only one out of ten thousand of such hospital deaths would be preventable!

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Most medical errors are medication errors. While reading x-rays and other medical images, thirty percent features in them- plainly visible or cryptic- are usually missed or poorly interpreted, which also lead to medical errors. Not only pregnant women and their babies but other patients also die in millions each year in hospitals due to surgical and medical mistakes hushed up by authorities. And medical errors are expensive too. When medical errors occur, the affected patients will need to be provided additional medical services. It will double the expense because the earlier medical condition of the patient before the medical error occurred is still remaining to be treated. So the world is burdened with an additional expense of around 3000 billion dollars on account of medical errors which could have been prevented from happening with a little care and diligence. The expenses which will have to be borne by the hospitals on account of these medical mistakes may even ruin those institutions financially, besides them sure losing their good names.

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Employee dissatisfaction is one major cause of medical errors.

Employee satisfaction is an important factor in ensuring patient safety in hospitals. It is when a professional is very weak and tired in mind and body that he or she is prone to making mistakes. Dearth of staff leads to professionals working twenty four to thirty six hours continuously in many hospitals, limiting their rest to intermittent ones in the call duty rooms between when their names are announced in the public address system. In such miserable conditions of hospital duty we cannot expect them to be always alert and function as well as when they are rested, washed and well fed. And the stress from their family problems arising from these unpredictable and ungodly hours of duty also adds to medical errors. The divorce rate among couples where one or the other is not a doctor is high. Burdened with loneliness, child support and alimony, not a few falter in the medical steps they take though they taking their own lives is rare; they take patients’ lives instead.

Have anyone tasted coffee from those vending machines in hospitals? Even a cup of decent coffee would not be available to them during their strenuous duty hours. Some good doctors, especially women, will have thought about retraining themselves and joining as nurses so that they could care for human beings without the responsibility for decision-taking. If one mistake happens due to their tiredness, there will be no one there to share their responsibility. The hospital administrators and the management who were primarily responsible for the overworking of doctors and their overall tiredness leading them to making mistakes will wash their hands and turn their backs at the very mention of a hospital mistake.

Even vigilant doctors cannot override electronic systems if needed.

In hospitals where they have automated a major part of patient care and treatment, the attending physicians and nurses won’t be able to read the full patient data in their monitors but only fragmented information due to a number of factors including computer glitches, technicians’ laxity in updating data and system failures or even their accessibility restrictions, and as there will be no conventional charts at the foot of the patients’ beds to read, they can make use of only this fragmented information to make decisions which may or may not lead to medical mistakes. In that event, they cannot defend themselves by saying that they were not responsible but it was the fragmentation of the information that led to the mistake. If they point fingers at the hospital’s automated system which the hospital management proudly boasts about in public relations, they will be dismissed with adverse remarks in their reports. Moreover, a vigilant doctor, if he or she ever detects a data error in the system, cannot override the system if needed. He cannot go beyond the set parameters and can do only what the systems says to do. (That is how the major chains of hospitals operate without engaging competent and highly-paid doctors in staff: they do not need them as the system can do the diagnostic and prescriptive things they are expected to do. Know that most of these systems refine themselves with each case, artificial intelligence helping not less).

In automated systems like these it is expected that who takes what action on which patient where at a given time is entered into the system in real time and all data will be available to all concerned to read but it happens only in code books, the result being no one takes any action on the patient at that given time. In reality most data unless it is meant for the billing department are entered only at a later date, usually after the patient is dead or discharged, most often only when it is noted by an administrator that a conspicuous backlog is there. This happens at institutions with only a rudimentary system and not (always) in hospitals which are part of world chain hospital systems. In those hospitals the doctors are not a significant part of the treatment anyway. The main drawback here is they are too reluctant to handover information on previous treatment of patients who are now admitted in hospitals outside their chain, for fear of exposure of their own mistakes.

Doctors’ pride prevents them from learning from subordinates and leads to medical mistakes.

Layers of protection are usually there for protecting patients from medical errors. If an attending physician or a nurse makes a mistake on medication, another staff in the pharmacy may pick it up immediately while dispensing those medicines and get it corrected. Or even the unit chief may pick it up. But if and where most of the staff is negligent, careless, sluggish and lazy, there is no safety for the patient.

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In most cases the pharmacists would know more about the adverse effects of some drugs on some patients. But most physicians will be unwilling to working in tandem with pharmacists in their hospitals, for reasons of unreasonable pride and self respect. The pharmacists too are experts in their field, and often more current in their knowledge of drugs notified with harmful effects the latest and their best available and safe substitutes to administer because they are not burdened with as tight a work schedule as physicians in a hospital and are probably getting more time to read and update themselves than doctors. Just by asking, their vast information on medication safety would have been available to doctors to select drugs and medicines between, but they do not ask.

Health departments have a system of circulating periodical reports of drugs slow-moving in various hospitals- a system by which a drug which is slow-moving in a hospital could be called for by another institution where it is very much needed but not in stock. In any hospital the pharmacists would be the first to know about these things, not doctors. They would also be the first to know about which drugs or which batches of drugs by which manufacturers have been called back from circulation and for what reasons. Though in the lower rung of hospital hierarchy after doctors and nurses, the pharmacists are the first to depend on to ensure medication safety.

Admitting medical mistakes to patients is better than covering up.

Cover-up of medical mistakes is not advisable under any circumstances even where such mistakes will not harm the patient much. A physician himself explaining to a patient a medical error soon after it has been committed is the best practice to be followed and the most advisable thing ever. The patient’s anxiety is considerably reduced once he learns what actually has happened to him. Even if it is an unrectifiable mistake, the knowledge of what has happened is a consolation in itself, or else he cannot associate the resultant problems with anything at all. Once told of the mistake he can relate the associated problems to that mistake. Though it is a shame for that physician in particular and that hospital in general to make a full admission of a medical mistake to a patient or his relatives, the truthfulness of the admission will not go unnoticed and will be beneficial to the system in the long run, though it will destroy the patient’s confidence in the system for a time. We cannot totally condemn a truthful man.

It is in mankind’s nature to forgive, though not to forget. Once explained to a patient why and how the medical error had happened, there is more chance of his forgiving, because it would not be the first time that he went to a hospital, got cured and sent away. He certainly will have to say a few good things about doctors, nurses, orderlies, cleaning staff in particular and hospitals in general from his past experiences. But is also strange to note that it is also in human nature when one gets healed, gets home and regains health and strength and resumes life as normal as it had been earlier to not remember that he had been in a hospital for several days, had been in a very critical condition and it was with the help of so many unknown people that he was brought back to life and health and comfort. But some good memories do linger and tend man to forgive. A word of apology from the responsible person would be enough.

Seventy percent of doctors look down on medical mistakes committed by their colleagues as heinous lowly crimes and respond unsympathetically to those doctors exposed thus, even while an equal percentage among them will remain indisposed to revealing their medical errors to their patients where those medical errors were committed by them. They do not even like using such words as ‘medical error’ and ‘admission of truth’ for that matter. So there is no use in seeking support of colleagues when medical mistakes occur. It is even better to admit these mistakes to the patients or the patients’ relatives. This admission or confession does not necessarily mean it will be invariably followed by a prosecution or a claim for compensation always. Many countries and many states in many countries have legislated making one’s own such voluntary confessions not admissible in court for prosecution. In fact, non-admission of the medical mistake would often be admissible as evidence in such cases.

The biggest killer element: the world of hushed up Never-Never-Incidents.

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Thousands of pregnant women die each year from Never-Never-Incidents which are hushed up in hospitals by authorities. These are incidents in the medical field that never should have happened- serious events which could have been prevented from happening which are becoming a great concern for mankind. They are termed ‘Never-Never-Incidents’- in common use Never Incidents or Never Events. They primarily occur from medical mistakes committed by medical professionals. There are medical mistakes as well as surgical mistakes. Suppose a surgeon looking at an x-ray film posted on a lighted wall in the operation theater operates on a kidney. He removes the wrong kidney without knowing that the x-ray film was posted there in reverse. So instead of living with one good kidney the patient will have to live for a few more months with one bad kidney- the good one having been removed-, undergoing costly dialysis everyday. Neither the doctor nor the hospital administrator will reveal this to anyone. They will not admit to anyone that a mistake had been committed. There will be a cover-up, a blanket put on the incident. The patient will not be told. So this is a surgical mistake- a Never Incident, a Never Event. There are also dozens of kinds of similar medical Never Events happening daily.

Operating on the wrong body part, doing the wrong operation on the body and operating on the wrong body are all never events. Malfunction of medical devices, contaminated drugs and medicines- all cause them. Leaving foreign bodies like scissors and cotton mop in patient’s body cavity after surgery is completed and the opening is sutured is very common. Wrong drug and wrong dozes cause them. Allergic and hemolytic reactions are common due to not conducting prior checks on the patient. Pregnant women die in scores each week due to carelessness in labor room care. Electrical systems and air vent systems may malfunction and microbes supposed to be kept out may come in unexpectedly without saying hello and spread throughout the theatre, wards and the entire hospital. Instead of oxygen other gases from other sources may come into ventilators and make patients dead or brain dead- making them vegetables for ever, requiring continuous life support till they are plugged out. Simple deliveries may become botched surgeries and bloodbaths. Wrong chemicals may be flowing through the intravenous lines. Even inept junior residents may misread senior doctors’ notations in medical records such as asap. and stat. and do funny deadly things on patients, needing them to be removed to freezers finally. (ASAP is acronym for As Soon As Possible and stat. is short for statim, meaning immediately). As the number of incompetent doctors increases, the number of Never-Never-Incidents also increases worldwide.

The numbers of Never Events are not small. Throughout the world there will be millions of such Never Events every year. Because of the cover-ups only a few persons will know about them and still fewer incidents will come out. Most of them will not even be reported to anyone or recorded anywhere. Because huge compensations will have to be paid, this cover ups will be very efficient and total. No medical ethics are pertinent or practiced here. If revealed, these incidents can cause many famous hospitals go under. In America in 2012 alone the numbers of medical mistakes were 1500 and surgical mistakes 4000- reported. Probably below one percent on what actually happened! And they say the Unites States is a developed country with a far advanced medical science!!

Following the hush-hush news of Never-Never-Incidents increasing in hospitals at unprecedented rates, the confidential investigation committees in America and England recommended four commendable actions to be taken following the occurrence of each Never Event in a hospital, namely, ‘apologize to the patient, report the incident, perform a root-cause analysis and waive costs directly related to the event borne by the patient’. But apologizing to the patient will make him or her know of the incident and file suit for damages, reporting the incident will result in the immediate dismissal of that doctor or nurse from service, performing root-cause analyses will bring to daylight all similar incidents happened in that hospital in the past and disgrace that hospital in the public’s eye, and waiving all costs borne by the patient directly related to the incident will again let the patient know of the incident when he gets the bill. So suppression and cover-ups of these incidents continued and these committees got only below one percent of all such cases reported in records, which still proved that there were ‘172 wrong body parts operated on and 97 foreign bodies left in patient’s bodies in ten months in England alone’! Imagine the number of Never Events going on in Asian countries including India each year!!

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About the Author P. S. Remesh Chandran:

00. Author Profile Of P S Remesh Chandran By Sahyadri Archives.

Editor of Sahyadri Books & Bloom Books, Trivandrum. Author of several books in English and in Malayalam. And also author of Swan: The Intelligent Picture Book. Born and brought up in the beautiful village of Nanniyode in the Sahya Mountain Valley in Trivandrum, in Kerala. Father British Council trained English teacher and Mother University educated. Matriculation with distinction and Pre Degree Studies in Science with National Merit Scholarship. Discontinued Diploma studies in Electronics and entered politics. Unmarried and single.