Saturday, November 22, 2014

Tough decisions

The holding tent outside the main hospital gates
Medecins Sans Frontiere are currently running a campaign called #toughdecisions. Initially I wasn’t sure what that meant but then it began to dawn on me. Working inside the isolation unit has its challenges but they can be trivial compared to those waiting just outside in the screening area. The first tough decision is which patients to choose to isolate.  It might sound like a cut and dried process but there are always grey areas. For example, a month of abdominal pain is very unlikely to be caused by Ebola as by then the patient would either have died or recovered. However, if the current symptoms are compatible with Ebola it is very hard to send them to the general hospital. You never know if you can fully rely on the history and even so it is possible to have Ebola as well as another longer lasting illness. Given the limitations of care in the isolation unit you really feel the patient would be better off in the hospital but on the other hand you are desperate to protect the staff from infection risk. While the bottom line must always be ‘if in doubt isolate’ you can’t help feeling for many on the borderline.
Tougher decisions still happen when there are more patients needing isolation than there are beds available and somehow we have to decide who is admitted.These patients wait in a temporary shelter just outside the hospital gates (see above). This is not a treatment area but a way of keeping track of patients and isolating them from passers by. Sometimes there might be 8 patients waiting, some are sitting up and talking, others are lying prostrate on the ground, in short it can look like a World War I medical area at times. Decideing who to admit may sound as simple as selecting the sickest patients; afterall they are the ones most likely to infect relatives if kept at home. However, some people have been sent by their families to get tested or have mild symptoms but be very anxious. Some might have sat outside the hospital all day or perhaps longer only to be told that a sicker patients has just arrived and will be given the bed. There are often patients in the holding area at the end of the day and they must either go home or wait until the morning (they are given a home kit with protective equipment and rehydration solution). Some may not have a home to go to as they have been rejected by their families after showing symptoms. Others may have family members with them pleading for you to take them in.
Choosing one patient over another under these circumstances has got to be the #toughestdecisions I’ve ever had to make as a doctor or a human being.

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