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Hope in healthcare

The health sector in Pakistan is facing a systematic collapse owing to the lack of state-of-the-art technology, adequate manpower and funding. The mere survival of Pakistan’s healthcare system itself holds miraculous happenings. Thousands of patients are estimated to visit out-patient departments and the emergency rooms (ERs) of government hospitals on a daily basis.

On an average, one in every 10 patients visiting ERs need to be taken care of at intensive care units (ICU). A hospital’s most critical patients can be found in ICUs battling between life and death and the state of these facilities is a tale of endless sorrow and grief.

Intensivists or critical care specialists are the physicians taking care of the critically ill in ICUs. These come from a pool of anesthesiologists, pulmonologists and specialists in internal medicine. Currently, only a few hospitals have trained intensivists.

Both public and private sector hospitals face a blatant lack of trained and qualified nursing staff as well as sufficient beds at ICUs. The number of surgical ICU beds at the Holy Family Hospital is as low as six whereas the medical ICU beds amount to at least 10. Ventilators share almost similar figures. The Benazir Bhutto Hospital has an even lower number of beds. According to recommendations from Britain, the number of beds at ICUs should ideally be six percent of the hospital beds. WHO recommends a 50:1 ratio of the general ward to ICU beds and a trained nurse for every ICU bed. But official reports in Pakistan say that, at present, one nurse is staffed for four patients in both private and public hospital ICUs. Moreover, private tertiary care hospitals have high charges for intensive and critical care units, with medical bills hitting a booming Rs100,000 mark for severely ill patients.

The 2017 census has shown that the population of Pakistan – excluding Gilgit-Baltistan and Azad Jammu and Kashmir – to be over 20 crore – a 57 percent increase since the 1998 census. Since the last census, Punjab has undergone a major population explosion but only a handful of new hospitals have opened up. The number of beds may have witnessed a benign increase. But the doctor-patient and population-bed ratios have worsened far beyond what previously was recorded.

Treating common non-malignant diseases has become a demanding task as it requires dynamic management involving meticulous attention to detail, rapid testing and interventions. All this requires a certain level of skills, which only a few individuals called intensivists possess. This leads to the burden being shared between registrars, postgraduate trainees and even house officers to provide 24-hour care to the critically ill at ICUs. Often the facility of urgent testing like CT scans, MRIs and ABGs (blood test) is not available. Immunological diseases require high-tech machines which are either not available or overused. They are often out of order.

Anesthesiologists – owing to their extensive medical knowledge and training in clinical physiology, pharmacology and resuscitation – are uniquely qualified to coordinate the care of patients at ICUs. They also possess the technical expertise to deal with emergencies by providing airway management, cardiopulmonary resuscitation, advanced life support and pain control.

Only 17 anesthesiologists cleared the Fellowship of the College of Physicians and Surgeons (FCPS) Part-II examination in the 51st session of the College of Physicians and Surgeons Pakistan (CPSP) and just two doctors graduated in critical care as super specialty (second fellowship) doctors. Regular announcements are made by the Punjab government for the increased need of anesthesiologists – even those with a simple diploma of one year are in demand. A low number of graduates from rigorous training programmes only adds insult to injury.

The amount of effort that goes into preparing skilled anesthesiologists or intensivists is astounding. Recently, three young anesthesiologists were reported to have suffered cardiac arrests in major tertiary setups. The stressful ICU conditions they work in must be acknowledged not only by the medical fraternity but also by the relevant authorities. Anesthesiologists and psychiatrists have the highest suicide rates in Western societies, with the average lifespan of anesthesiologists being 10 years less than other physicians.

Perhaps a lesson could be drawn from two stalwarts in Karachi who refrain from beating the drum and instead focus solely on providing optimal critical care facilities. These are the Jinnah Postgraduate Medical Centre, which provide free-of-charge treatment in its 60-bed intensive care facility, and Civil Hospital, which renders free treatment in its three separate surgical, medical and neurological critical care units.

If the current scenario prevails, any hope of the health sector being revamped stands shattered. The concerned authorities should consider every specialty according to its demands and needs. At ICUs the margin between life and death is nominal. Alleviating the standards of such facilities can tilt the balance in favour of life.

The writers are medical doctors based in Islamabad.

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