Ethical Dilemmas and Medical Malpractice
One of the hardest parts of being in the field, for me at least, is the sense of being in a liminal space-not quite actor, not quite detached observer. In my situation at the regional hospital, I am also torn between a desire to help the women who come to the hospital seeking care, particularly when I feel their rights have been violated, and my need to maintain strong relationships of trust with the health care providers in order to protect my own work.
The times when this is most problematic are the times when I know something has gone wrong; a woman or her baby has been injured due to miscommunication, neglect, or malpractice. Who's side am I on and how do I proceed? I struggle with ways in which I might be able to resolve my internal conflict about these types of incidences. This is particularly difficult in a setting in which there is no real, formal mechanism for patients to express their concerns about their care, or if there is, no one knows about it, not even me. It also seems that there is no real mechanism for disciplining those providers who might have made a mistake. Patients often have low levels of formal education and do not receive adequate care and education during their pregnancies. This makes it even more difficult for them to know when something has gone wrong. Women and their family often have nothing more than a hunch that perhaps something did not happen as it should have. In other areas of Tanzania, I have heard that medical malpractice cases are being pursued more frequently but here in Sumbawanga it seems there has not yet been a court case related to medical care, at least not in maternity. Twice now I've witnessed cases that have gone wrong and ultimately resulted in stillbirths and, in one of the cases, the woman's uterus ruptured.
There's no electronic fetal monitoring to alert nurses to a baby in distress, there are no call buttons to push in an emergency, only the vigilance and diligence of the nurses, who are already spread thin. Less than thorough reports during shift changes and abysmal use of partographs to chart a woman's progress in labor seem to be contributing factors, among others. But now, in this latest case, the partograph has gone missing and wouldn't even be able to be used in a legal case even if the family were to want restitution. Without that documentation it would be virtually impossible to prove any wrong doing. The nurse in charge of the ward is certain someone hid the partograph.
As I watched a 22-year old take pictures of her stillborn son with her cell phone camera and ask her mother to see the baby's feet, I couldn't help but be deeply moved. In that moment, I thought of the phone call from the woman's husband, across the country in Dar es Salaam, that I had taken during visiting hours the day before. I was the only "staff person" around and so the phone was passed to me. Immediately, the woman's husband began demanding answers, wanting to know how a baby who was fine could suddenly be not fine and why hadn't she had an operation sooner and he didn't believe it was bahati mbaya, bad luck. He wanted to know if I had done the surgery. I explained that no, I had not. In fact, the surgeon was the Medical Officer In Charge (MO I/C) of the entire hospital. Nothing had gone wrong during the surgery. I tried to tell him that I wasn't the one he should talk to, that he should talk to the Nurse In Charge of the ward or the MO I/C and they would be better able to explain to him what had happened. The truth of the matter is that I knew exactly what happened and had been involved since the very beginning, though the course of events that transpired had nothing to do with me or anything I did. In fact, I was also there when we discovered she should have been taken for a C-section hours and hours earlier. I wanted so much to tell that man, "Yes! You have a case here! I will tell you exactly what when wrong and then I want you to take it to a lawyer." But instead, all I felt I was able to do was tell him he needed to talk to someone other than me, someone who actually worked for the hospital. In the end, I did the little things I could, like make sure that the woman's mother could take the baby's body to show the woman so she could know her baby's face. I told her her husband could call again on Friday to talk to the MO I/C. She told me he didn't want to talk to anyone anymore and they had been able to explain to him that this kind of "bad luck" happens. And now, I am working on setting up a system to organize patient files and partographs by time so everyone knows, without fail, when a woman needs to be checked again so this same thing doesn't hurt another family. Maybe something as simple as a tabletop file box will have the ability to improve care, no one else here has ever tried. The crucial question is whether or not the nurses will be persuaded to change their routines to include a new system. Without different routines, countless interventions have been implemented and failed, but more on that in another post.