HT Spotlight: One doctor for 30 patients, it’s a pressure cooker situation in PGIMER emergency
Boiling point: With one overburdened doctor examining at least 30 patients at the PGIMER emergency section, unable to give more than five minutes to each, the need for effective patient management is being felt more than ever now.punjab Updated: Mar 15, 2018 21:07 IST
Chandigarh The loud, angry voice stabbed the silence of the emergency ward. “What did I tell you?Tell me, what did I tell you in the morning? Say it out loud,” an angry young resident doctor was shouting at a humble, turbaned man in his fifties, who could only mumble a response, wipe his tears and leave the ward quickly.
When asked what the man done to evoke the doctor’s ire, the quiet response was: “I had asked him when my relative will get discharged.” There’s nothing unusual about doctors losing their cool in any hospital’s emergency unit, where they have to constantly deal with high-pressure situations, making life and death decisions in seconds, dealing with the terminally ill or the terribly sick.
The country’s premier hospital- Post Graduate Institute of Medical College and Research (PGIMER) is not an exception.
- There are 110 beds and 300 plus patients in the emergency at any given point of time.
- About 150 to 200 patients remain admitted at the most overburdened unit of the emergency, the EMOPD, at a given point.
- From 6am on Tuesday to 6am on Wednesday 171 patients were registered at the EMOPD. “There are only three senior residents and six to seven junior residents in one shift at the EMOPD, which comes to around 10 resident doctors for 171 patients,” said Dr Sandeep Tula, vice-president, Association of Resident Doctors.
- However, as per data provided by PR department, PGIMER, there are 39 to 40 resident doctors in the morning shift and 26 to 27 in the night shift.
- Contrary to junior resident doctors who work for over 16 hours per shift, the nursing staff works in three shifts.
- There are 60 nurses in the morning shift, 50 in the evening and 45 at night. The number of hospital attendants is 10 to 20 per shift.
Often, knowing what doctors have to deal with, most patients and their attendants keep quiet. Sometimes, however, situations can go out of hand. In 2016, an attendant lost his cool and slapped a doctor for rude behaviour, which led to a doctors striking work for nearly two days, highlighting the inhuman working conditions. Memorandums were submitted to the then director and written assurances were given.
A year later, however, nothing seems to have improved, and to assess the situation on the ground, this correspondent spent some time at the PGIMER emergency interacting with the doctors and other staff working there.
Right in the middle of a war zone
Here every inch of space is being utilised to adjust patients. Doctors work 18 hours at stretch, at times without breaks. From one entrance to another, you will see a ‘sea’ of patients lying on trolleys, either writhing in pain or unconscious.
From the entrance of the emergency, to pathways, waiting halls, areas near toilets, even outside one of the exit areas, you see patients everywhere.
The doctors have even created a triage area - sorting out patients in groups based on their needs, as is common in all emergencies and in battlefields or disaster sites. Every patient in the ‘triage’ is examined and based on the criticality referred to different areas.
There’s a lot of action happening here - as one trolley is wheeled in after another, doctors, paramedical staff rush in to take charge of patients. Two junior residents are on duty here.
The PGI’s emergency outpatient department, or EMOPD, which receives the maximum number of patients, is divided into Hall A (red area), Hall C (yellow area) and ‘L’ shape area (the passage in front of hall A and that turns left towards trauma).
The EMOPD gets at least 70 new patients during the day and about 80 during the night. At a given point in time about 150 to 200 patients are admitted here, which is five times more than what this unit can handle. Going by the guidelines of the Australasian College of Emergency Medicine, the area here is adequate only for around 29,000 patients a year - which means 80 patients a day, and not necessarily all at one time.
From the triage, critical patients are shifted to Hall A- Red area which has three rows of trolleys, with 15 to 20 patients in each row. Most of them are unconscious and on oxygen support.
During the day one senior resident, four to five junior residents and one consultant are on duty here.
While senior residents examine old patients, only two junior residents examine new patients while the other two to three junior residents do sampling work. Consultants only pay visits.
“In Hall A, one senior doctor examines around 30 old patients, and two junior residents examine 60 to 70 new patients. Which means that one doctor examines 30 to 40 patients, whereas ideally the number should be four to five patients per doctor, as the emergency is just like an ICU, where every patient needs close monitoring and proper care,” says a senior resident doctor.
Four to five nurses and only one hospital attendant are present to support the doctors.
Hall-C, once a waiting area now converted to a yellow area, gets the slightly less critical patients. The room is tightly packed with trolleys parked back to back in six rows, one row having 13 to 15 trolleys.
“There is only one senior resident who examines about 30 to 40 old patients here. One junior resident looks after the 25 to 30 new patients during the day. Another junior resident is on duty to collect samples. There are two nurses to help the doctors and no hospital attendants,” says a resident doctor.
About 45-50 patients on trolleys are accommodated in the L shaped area.
Resident doctors running the show
The emergency runs on the strength of its resident doctors, who have to be on their toes for 16 to 18 hours a day. According to a study conducted by the School of Public health of PGIMER in 2014, the guidelines adopted by the American Academy of Emergency Medicine say that one physician is required per 2.5 patients per hour and the nurse-patient ratio should not exceed 1:3. Yet, in the emergency, 10 to11 resident doctors and 12 to14 nurses cater to a daily load of at least 150 patients.
A senior resident, talking about the work load, says, “They (patients) expect immediate results, which usually cannot happen. A person must be patient. While I am examining one patient, attendants of two more patients want me to examine their patients. At times, it becomes very difficult to manage.”
Today this doctor has examined 20 new patients, yesterday it was 25 and one day it was 40. “That’s a big number as we have to evaluate the patient’s condition minutely and it takes time to prepare their files, getting all the tests done and arriving at the correct diagnosis.”
When asked how much time he gets for each patient, the doctor says he has to first make the initial diagnosis quickly within five minutes whereas 10 minutes would be ideal.
“I am under stress, lots of stress, even when I’m talking to you I am thinking about my patients. No wonder, a doctor from the hospital recently committed suicide,” he says, lowering his voice.
What’s life like for doctors like him after 18 hours a day at the emergency? “I report here at 8am and leave at 1:30 or 2 at night. At times, the only meal I have in a day is dinner,” he adds.
Today he has called his mother after two weeks, but spoke to her “just for five minutes.”
When asked what keeps him motivated, he says “I keep on convincing myself that I am helping others. By working hard I am saving lives.”
“My father has stomach cancer abd he’s being treated at PGIMER for the last six months. He underwent surgery a month ago. Today he developed some complications and we rushed him here. The health facilities in our home town are very poor. There, the doctors can only do minor surgeries and they refer every complicated case to PGIMER.” — Mohan Chauhan, from Sirmaur
Senior doctors at the PGIMER emergency point to a number of solutions to manage the rush. Some of these are:
Strengthen the peripheral health system:
About 40% to 50% of the patients referred to the PGIMER emergency can be easily managed in the periphery hospitals. Patients with kidney ailments for emergency dialysis come from cities 400 to 500 km away and should be managed by hospitals in their areas.
Hire more phlebotomists
Junior residents, doctors say often have to do the work of technicians or nurses. There are seven to eight junior residents in the EMOPD and most of them are doing sampling. The administration should hire phelbotomists for drawing blood for clinical or medical testing to free the other junior residents to examine patients.
More doctors needed
Though the number of patients is growing, there’s no change in the strength of doctors at the emergency - the administration should at least double the number of doctors there.
Improved doctor-patient ratio required
Currently, one doctor is examining at least 30 patients in emergency whereas ideally the number should not be more than 10-15 patients per doctor.
Right to refer back patients
Doctors should have the right to refer back patients to their parent hospital after they have been stabilised.