MDB Reflection - Pooja Makhijani
“We are a public hospital, we should be able to treat all children that need us,” one of the medical officers in the pediatric intensive care unit lamented. He was referring to an infant who was to be taken off intubation later that day due to uncertainty in prognosis and the financial burdens that accompanied.
It is always easy to place responsibility on the physicians, especially in cultures where ‘a good doctor can always fix you’. I recall my summer spent in India studying such cultural beliefs where families switched doctors readily if they did not recover quickly. In Nepal, my attending assigned to this patient had expressed frustration that she has not yet had the opportunity to complete an intensive care fellowship. She had, however, supported regional training, studied independently, and encouraged constant learning. One could also wonder if things would have been different if there had been a trained pediatric cardiologist or pediatric surgeon who could intervene in this infant's care.
Access to drugs and supplies limited both the potential for treatment and comfort. The patient could not be adequately sedated by following the standard ICU protocols, but alternative medications were not available. His ventilator had stopped working and the equivalent ventilator had to be given to another infant with more severe needs. The patient was left to use an old mechanical ventilator that did not suit his needs as well as the first had.
I had also completed online literature searches in case the books used by my team were missing something. However, my suggestions for drug alternatives were met by financial concerns or lack of accessibility – many drugs were not available in the region and the difference between 15 cents and 90 cents per dose made a drug prohibitive. It helped me realize that many studies, particularly newer studies, involved drugs and techniques that were not necessarily appropriate in these settings. And if a treatment is not definitive, it is difficult to warrant the cost.
The physicians and staff did their part to decrease costs and prolong treatment. The medical officer aforementioned had petitioned for the patient to receive coverage from the hospital. When the prognosis remains uncertain regardless of treatment, however, it is difficult to justify allocating finances. After difficult conversations, many tears, and what felt like an unceremonious goodbye, he was taken off the respirator and sent home.
The physicians I observed were dedicated, ready to take every step possible, and go out of their way for their patients – but the rules of care were different. Although having limited resources changed the conversation, the questions that led to these decisions were not so foreign. What can we do? What should we do? What is most important for this patient and their family? The cultural aspect and local context of these questions and how the answer changed in this setting will be something I carry forward.
Pooja Makhijani is a final year Stanford Medical Student interested in global health, education, and critical care applying into Anesthesia Residency this fall. She plans to continue engaging in the global community during her training and hopes to return to Nepal soon. Her rotation at Patan Hospital was supported by the Mary Duke Biddle Scholars Program.