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Sunday, April 20, 2014

When emergency beckons

Last part of a series

The baby is screaming. “We’re in the emergency room,” the father says on his cell phone. He is in the hallway, pacing back and forth. He cannot talk on the phone inside the examination room with the baby screaming. The mother is rubbing her son’s back. But the baby continues crying.

The nurses have taken the baby’s blood sample and sent it the laboratory for testing. The parents wait.

Half an hour later, Dr. Shirish Balachandra walks in. “We’re still waiting for the results.”

Balachandra is three hours away from finishing his 12-hour shift. But it’s Friday, usually a busy day with parents off from work. They have time to take their children to the emergency medicine department of the Commonwealth Health Center.

“On weekend the ER also becomes a children’s clinic. We’re treating not really emergency cases … mostly runny noses, diarrhea and vomiting, which you can take care of [by drinking] ginger ale,” says Gregory Kotheimer, head of the Emergency Medicine Department. These patients are indigent and could not afford to go to a private clinic. “They have no place else to go.”

The baby has a boil on his butt. From the outset, it is obvious to Balachandra that the boil should be drained. But not without first getting the baby’s vital statistics and laboratory exam results. And definitely not without the doctor having a pep talk with the parents, explaining the procedure and the risks.

Balachandra: We have to make him sleep so he does not to feel the pain. It’s the only humane way to do it.

Baby’s father: Can we do this today? The sooner, the better.

Balanchandra: Yes. Why wait till it gets worse? Let’s just get the result on his blood work to make sure there’s nothing to worry about. …We’ll put him on an IV. He’ll be essentially out.

Baby’s father: Is he going to be admitted?

Balachandra: Yeah. We have to keep him for observation for a little while because, you know, we will use a mild level of anesthesia. So you have to keep him here for at least 24 hours. Okay? Is that reasonable to you?

Baby’s father: Yes, thank you.

Balachandra walks back to the nurses’ station to study the laboratory results and make phone calls. Speaking in French, he requests a Canadian respiratory therapist to make sure that the sedated child will continue breathing during the procedure, which essentially entails draining the abscess on his butt.

Less than an hour later the procedure is done, the baby and his parents leave the ER and Balachandra moves on to the next patient.
Balachandra, 35, is one of the three doctors on rotation at the ER. Born in Illinois, he grew up in Los Angeles, Calif., and lived in India, Honduras, France and Cameroon, where he worked as a U.S. Peace Corps volunteer, serving Somali and Liberia refugees in the area. He studied molecular biology and French literature at the University of California Berkley and went to medical school at McGill University in Montréal, Canada.

In May 2008, he moved to the island with his wife, April, a midwife at CHC, and kids. “We were looking for opportunities to work in underserved areas … and looking for simpler lifestyle for our kids,” he says.

“I love my job. I love going to work everyday. Mostly patients are fantastic. They are down to earth, sensible people who have reasonable expectations on what we can and cannot accomplish,” the soft-spoken Balachandra says of his stint at the ER.

The ER is a hospital’s window to its community. The situation there reflects how the hospital is being run, or in the case of CHC, “mismanaged,” according to the CNMI House of Representatives’ Committee on Health, Education, and Welfare.

Chaired by Rep. Ralph DLG. Torres, the HEW committee recently directed its attention to CHC following constituents’ complaints over the long hours of wait at the ER.

Two doors lead patients to the ER: the first facing the parking lot is where ambulances pull in to rush critical or injured patients; the second entrance inside the building is where a number of patients sit on rows of chairs, waiting sometimes for up to four hours to see a doctor. The ER is where most of the criticisms of CHC emanate.

The nine-bed ER is open 24 hours daily with at least one doctor and a team of five nurses—all U.S. licensed—on duty. The walls are painted white with royal blue trimmings, matching the color of the nurses’ uniform. On one wall is a bulletin board announcing schedule, memoranda and other notices. On the other side is a giant whiteboard showing the names of doctors who are on-call and in-charge of a particular work shift.

Doctors and nurses seem to get along well. Kotheimer occasionally brings stuffed animals to give away to nurses, who keep the doctors’ mugs filled with coffee. But once a patient comes in, they all buckle down to work, rushing about between the rooms and the nurses’ station.

“The nurses are fantastic,” says Balachandra, who has learned some Filipino words over the past year. Most, if not all, ER nurses are from the Philippines. “[The nurses] anticipate the needs of the patients. Their skill set is excellent and their work ethic is great.”

The nurses manage triage, the sorting of patients to determine medical priority.

“If [patients] come in with chronic or non-urgent complaints then they go to the bottom of the list. If [patients] are waiting, that is because they can afford to wait,” Balachandra explains. “If someone is suffering a heart attack, they are put in bed within a minute and they get two or three people taking care of them immediately,” he assures.
One main reason the ER has turned into a children’s clinic is because the hospital does not have enough physicians to keep the pediatrician’s clinic open. Dr. Tutet Nguyen, pediatrician, resigned along with her husband, Dr. Florian Braig, an ear, eyes, nose and throat specialist at CHC. Both were hired from Canada.

The closing of the pediatrician’s clinic indicates a bigger problem at CHC: the exodus of physicians. Nguyen and Braig are not the only ones who left CHC this year. Personnel records from the Department of Public Health, which operates CHC, show that 26 doctors resigned in 2009 alone; 20 in 2008; 18 in 2007; and seven in 2006.

At a recent oversight hearing by the HEW committee, DPH’s human resources manager Marciana D. Igitol explained that the high turnover could be because a number of doctors were hired as locum or temporary, which means they have to leave the hospital after three months of working. However, other full-time doctors “opted to not renew for better pay,” she said.

Low salary has been a major sticking point for doctors at CHC. Kotheimer, also the hospital’s acting chief of staff beginning Sept. 1, 2009, admits he is becoming tired of hearing doctors saying how much they could be making if they were in the mainland U.S.

Emergency physicians in the mainland U.S. are receiving $120 per hour whereas Kotheimer and his ER colleagues are getting only $70 per hour. This disparity in salaries is compounded by the amount of time doctors have to put in. For some doctors, it is disappointing to be on an island like Saipan and not enjoy the beaches.

“It’s a balance between pay and lifestyle. If [doctors] have lifestyle then they don’t mind the pay. But if you don’t have a lifestyle and pay is too low then you get frustrated,” points out Kotheimer, who worked in a hospital in Riyadh, Saudi Arabia before moving to CHC four years ago.

Salaries should go up, Kotheimer warns. Otherwise, “you will start to get underqualified people, which is going to be very difficult here because we have U.S. standards,” he says. Since Medicare (federal health insurance for people aged 65 years old and above) and Medicaid (federal health insurance for indigents) pay a portion of the medical bills, CHC has to abide by the health care criteria set by these two federal agencies. One of those criteria is that doctors should be either U.S.- or Canada-licensed.

Even though he is an internal medicine specialist, Kotheimer has been thrust into filling a 12-hour shift because CHC suffers from a dearth of emergency-trained doctors. “Somebody has to fill the shift. We are trying to keep this place open,” he says.

On some weeks he works for 72 hours, way beyond the ER standard of a 36-hour workweek. Unless this trend stops, Kotheimer says, “as soon as my wife passes the NCLEX [a U.S. nursing licensure exam] I am out of here.”

To address the lack of doctors, Gov. Benigno R. Fitial declared in September 2009 a state of emergency for DPH. Fitial believed this would allow government to hire doctors from the Philippines to cover some shifts at the ER.

However, Kotheimer points out, “It won’t work [at the ER]. They cannot order narcotics. They cannot work here.” Doctors cannot prescribe medicine unless they are registered with the U.S. Drug Enforcement Administration. Doctors from the Philippines are not.

Besides salaries, doctors also complain about the lack of appropriate diagnostic equipment at CHC.

Former CHC medical director Edward Cornett said DPH management “should be more honest with the doctors” about the situation at the hospital instead of making false promises during recruitment.

For example, a recent job announcement, which Enterprise Medical Services released on behalf of DPH, read: “Have you ever thought of island living while still practicing high quality medicine? This is the opportunity for you! …Solid specialty back up and immediate access to CT Scan and ultrasonography.”

“But we come here and we have no needed medical tools to make proper diagnosis,” said Cornett, who was also CHC’s director of Emergency Medicine for two years until he resigned in April 2008. “The CT scanner over here is ridiculously old. It is essentially worthless.”

The CT scanner (computed tomography) has never been upgraded since the hospital opened in November 1986. Cornett said CHC needs a 64-slice CT scanner to get image data from different angles and several types of tissue around the body. The market cost for a CT scanner $1.5 million.

The absence of this CT scanner spells trouble for the CNMI where a considerable number of people are obese, diabetic, or leading a sedentary lifestyle. Cornett said these people are at risk of suffering from pulmonary embolism, a blood clot that ends up in the lung. This type of disease can be diagnosed when a patient gets pulmonary angiogram or x-ray of the blood vessels using the CT scanner.

“Do you know how many pulmonary emboli that we missed here? We can’t make the diagnosis—a very simple diagnosis of a very deadly disease process,” Cornett said.

There was also a time when CHC ran out of “packed red blood cells” for transfusion and some suture materials—all basic needs in running an ER.

“The list is nauseating. You need the tools in order to give quality medicine here and we don’t have it,” Cornett said.
Just as Balachandra is ending his 12-hour shift, a laboratory technician walks in to report that they no longer have Troponin, a reagent necessary in diagnosing heart attack.

“The problem with the lab is that the hospital has not paid the vendor. They have some outstanding balance since May amounting to $70,000,” Balachandra says. “That’s a little bit frustrating.”

Until 2003, CHC had been procuring medical supplies through the U.S. Department of Health and Human Services. “But they stopped delivering because we could not pay on time,” said Medical Supplies Office manager Jose A. Ichihara. A military retiree, Ichihara, 60, has been with CHC since 1992.

Ichihara said his office is responsible for buying the common everyday supplies such as gloves, suture materials and gauze pads for the hospital including the ER. But for operational supplies like reagents, each unit manager is responsible for replenishing them. “Only managers, say for the operating room or the intensive care unit, for instance, know what supplies are needed for their respective department,” he said.

However, unit managers could not replenish their supplies on time because the CNMI Department of Finance does not have enough cash flow to pay the vendors. “Any company won’t deliver unless you pay,” Ichihara said. Procurement issues are further compounded because of shipping costs. “Even if we manage to get the supplies at a discounted price, we still have to pay extra for freight costs,” he said.

Regardless of the occasional supply shortages and grumbles about salaries, Kotheimer says, “We’ve got a good crew. They are conscientious. I hope the Legislature ends up raising salaries. If they can do that then everything will be just fine.”

Meanwhile, Kotheimer assures that they will continue treating non-emergency cases. “It’s okay. We’re here to serve. Our motto is saving lives one at a time.”

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