So its been a while since I last blogged & it wasn't because I didn't have anything to say, in fact quite the opposite. But my silence has been broken by part 4 of the patient with WPW syndrome saga. If you remember M was the 17 year old girl that the ICU staff at my hospital nearly sent home to die. I won't go through all the details again as it still makes me angry but the outcome was a failed Ablation (burning of the accessory pathway causing the tachyarrhythmia) but the promise of a repeat try in February when a group of American Cardiologists would be visiting.
So its February now & after ensuring that the Flecainide we had bought from donated funds had been stopped (can't do an ablation if the patient is on anti-arrhythmics) and confirming the date of admission & procedure we booked a bus to take M & her Mum down for a second attempt.
I am an idiot - people who know me will know this to be true. I emailed Dr C - the Cambodian Cardiologist - the week before confirming the date & asking for written confirmation that she would not need to pay for the procedure again which I got BUT I did not re-confirm the day before. More fool me.
I was feeling proud that we had successfully got them on the bus & given sufficient funds to the health equity fund (HEF) to pay for her user fee & additional fees. I assumed that it would all go smoothly if I wasn't there as a walking dollar sign & just let the HEF advocate for the patient. We all know what assumption is the mother of!
L - my VA - has spent a lot of time on the phone with M's mum. Without their good communication nothing good would have ever happened. The Mum told Liong to tell me not to worry - they would be fine. Easier said than done.
HEF met them off the bus & paid for a tuk tuk to the hospital, then it all went pear shaped. The hospital sent them away until Friday - no explanation. Luckily they have a relative who lives in Phnom Penh. I rang the Cambodian Cardiologist Dr C - no answer, I texted Dr C - no reply & emailed - still waiting now for a response. Eventually with some investigation & after they had met with Dr C the following day it became clear the Americans were coming a week later - always nice to have good communication & all the information.
They were sent away & told to come back in 2 days. HEF gave them the standard rate to live an a day R5000, that $1.25. M's Mum told L that the staff were rude & mean to her but when she felt scared & sad she just thought about me because she knew I was a doctor that actually cared. This still upsets me to think about it.
She finally was successful in getting an admission to hospital & was seen & operated on the following Monday. By chance I happened to be in PNH that week so could go & visit her. One look at the monitor revealed the second ablation had not been successful. M's Mum was hugging me & so pleased to see me - I just wanted to cry.
It turned out from what I could gather via translation from Liong on the phone & Rady who came with me to visit her, that the Cardiologists had tried to ablate but the accessory pathway was too close to her AV node & there was concern that if they ablated it they would put her into complete heart block. Pacemaker care is not so good here. This was mildly disappointing. Cambodia has prepared me well for disappointment but this one really stung.
She was then inexplicably kept in for the next 3 days, this was clearly not due to clinical need but more financially related. This greed & corruption actually went in M's favour in the end.
I was in PNH for a conference which by coincidence was where the Cardiologists from the states were staying. I tried to get their contact details by asking at reception & emailing Dr C - no luck. But one morning I had lost my phone & was rushing back to my guest house to find it when I literally bumped into them. It was the stethoscope around his neck & the clipboard with a list titled (in big bold letters) 'PATIENTS FOR ABLATION" that gave it away.
I explained who I was & we discussed M's case. No one had told the american cardiologist Dr Ch about how ill she had been previously or how poor she was. They had thought she could buy a years supply of Flecainide & they would come back next year with different equipment. When I explained she couldn't afford that & we had used all the money raised so far on the first & second failed ablations & the 3 months of medication, they offered to provide the medication for free.
They couldn't believe she was still an inpatient - there was no clinical reason but obviously the reason she was still in hospital was not clinical. But seeing me had then prompted Dr Ch to check on her - and he found her in SVT at a rate of 180/minute. It would seem that even in the cardiac ward of the biggest hospital in Cambodia staff don't recognise or more likely don't care about life threatening conditions in patients if they are poor. No money, no life.
It was lucky that I lost my phone, it was serendipitous that I bumped into Dr Ch in the hotel lobby & it is heaven sent that Dr Ch on seeing her clinical condition took her back for a third attempt at ablation.
He called me afterwards to let me know that after 5 hours he was pretty certain that he had damaged enough of the pathway to prevent further life threatening arrhythmia. He was so confident that he was happy for her to go home without medication & if she does develop further SVT it can be controlled with cheap & easily available B-blockers.
M looked well when I went to see her that evening, her Mum was relieved & was keen to get out of PNH & back home.
Janice, Elaine, Joan, Ruth, Hannah, Liong, Dr Ch & HEF - thank you for giving me the best 40th Birthday Present.
M - you just need to stay in sinus rhythm - please!
So its February now & after ensuring that the Flecainide we had bought from donated funds had been stopped (can't do an ablation if the patient is on anti-arrhythmics) and confirming the date of admission & procedure we booked a bus to take M & her Mum down for a second attempt.
I am an idiot - people who know me will know this to be true. I emailed Dr C - the Cambodian Cardiologist - the week before confirming the date & asking for written confirmation that she would not need to pay for the procedure again which I got BUT I did not re-confirm the day before. More fool me.
I was feeling proud that we had successfully got them on the bus & given sufficient funds to the health equity fund (HEF) to pay for her user fee & additional fees. I assumed that it would all go smoothly if I wasn't there as a walking dollar sign & just let the HEF advocate for the patient. We all know what assumption is the mother of!
L - my VA - has spent a lot of time on the phone with M's mum. Without their good communication nothing good would have ever happened. The Mum told Liong to tell me not to worry - they would be fine. Easier said than done.
HEF met them off the bus & paid for a tuk tuk to the hospital, then it all went pear shaped. The hospital sent them away until Friday - no explanation. Luckily they have a relative who lives in Phnom Penh. I rang the Cambodian Cardiologist Dr C - no answer, I texted Dr C - no reply & emailed - still waiting now for a response. Eventually with some investigation & after they had met with Dr C the following day it became clear the Americans were coming a week later - always nice to have good communication & all the information.
They were sent away & told to come back in 2 days. HEF gave them the standard rate to live an a day R5000, that $1.25. M's Mum told L that the staff were rude & mean to her but when she felt scared & sad she just thought about me because she knew I was a doctor that actually cared. This still upsets me to think about it.
She finally was successful in getting an admission to hospital & was seen & operated on the following Monday. By chance I happened to be in PNH that week so could go & visit her. One look at the monitor revealed the second ablation had not been successful. M's Mum was hugging me & so pleased to see me - I just wanted to cry.
It turned out from what I could gather via translation from Liong on the phone & Rady who came with me to visit her, that the Cardiologists had tried to ablate but the accessory pathway was too close to her AV node & there was concern that if they ablated it they would put her into complete heart block. Pacemaker care is not so good here. This was mildly disappointing. Cambodia has prepared me well for disappointment but this one really stung.
She was then inexplicably kept in for the next 3 days, this was clearly not due to clinical need but more financially related. This greed & corruption actually went in M's favour in the end.
I was in PNH for a conference which by coincidence was where the Cardiologists from the states were staying. I tried to get their contact details by asking at reception & emailing Dr C - no luck. But one morning I had lost my phone & was rushing back to my guest house to find it when I literally bumped into them. It was the stethoscope around his neck & the clipboard with a list titled (in big bold letters) 'PATIENTS FOR ABLATION" that gave it away.
I explained who I was & we discussed M's case. No one had told the american cardiologist Dr Ch about how ill she had been previously or how poor she was. They had thought she could buy a years supply of Flecainide & they would come back next year with different equipment. When I explained she couldn't afford that & we had used all the money raised so far on the first & second failed ablations & the 3 months of medication, they offered to provide the medication for free.
They couldn't believe she was still an inpatient - there was no clinical reason but obviously the reason she was still in hospital was not clinical. But seeing me had then prompted Dr Ch to check on her - and he found her in SVT at a rate of 180/minute. It would seem that even in the cardiac ward of the biggest hospital in Cambodia staff don't recognise or more likely don't care about life threatening conditions in patients if they are poor. No money, no life.
It was lucky that I lost my phone, it was serendipitous that I bumped into Dr Ch in the hotel lobby & it is heaven sent that Dr Ch on seeing her clinical condition took her back for a third attempt at ablation.
He called me afterwards to let me know that after 5 hours he was pretty certain that he had damaged enough of the pathway to prevent further life threatening arrhythmia. He was so confident that he was happy for her to go home without medication & if she does develop further SVT it can be controlled with cheap & easily available B-blockers.
M looked well when I went to see her that evening, her Mum was relieved & was keen to get out of PNH & back home.
Janice, Elaine, Joan, Ruth, Hannah, Liong, Dr Ch & HEF - thank you for giving me the best 40th Birthday Present.
M - you just need to stay in sinus rhythm - please!
How did I miss this one!!!! Wonderful news. Sometimes the fates are smiling down on us (this doesn't sound like the right pithy saying - I've obviously been in Cambodia too long and can't remember my own language!)
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