How to work without medicines and equipment: straight story of the Russian physician
In October Russia’s Ministry of health announced the launch of “large-scale national project” <ahref=”http: www.roszdravnadzor.ru=”” i=”” upload=”” images=”” 2018=”” 7=”” 25=”” 1532512237.26174-1-15781.pdf”=”” target=”_blank”>”Health”. Officials promise that in six years the mortality rate of the working population will decrease by more than a quarter of infant — 19.6 percent. Breakthrough by increasing the availability of advanced medical care. The main providers and facilitators of good health must become a National research and development centers. Today they are 22 — in almost every branch of medicine. It is implied that some shortcomings and problems are regional in medicine, and in the Federal agencies concentrated all the best: staffing, equipment, drugs. On the website “Doctors.of the Russian Federation” published an open letter about the lack of basic drugs and good equipment in the National medical research centre of surgery named. A. V. Vishnevsky Of The Ministry Of Health Of Russia. In medical social networks many fellow commentators wrote that this health — anywhere and everywhere. However, the official broadcast, that is getting better and better. “Ribbon.ru” talked to the author of treatment — surgery, senior researcher NMISA Olga Entraceway on why she started to fight the system and is it true that in hospitals today is better come with all your.
“Ribbon.ru”: Today, doctors are afraid once again to admit that they have at the hospital, something was missing. The official position of the Ministry of health: we are all great. Why you do not correct speech production, the boat rocking?
Olga Andreytsev: Work has become hard and uncomfortable. The doctor put in a humiliating position. We are now happy and proud I can’t, what the patient saved. On the contrary — the doctor feels guilty that his heavy patient lives, although all indicators have long “down”. You feel ashamed that, helping the patient, you are ruining the institution of their work, colleagues leaving without a prize.
You are talking theoretically, or are there real cases of discontent, “being alive”?
I had a very heavy patient with necrosis, which developed after surgery. Five months is not out of intensive care. And on Saturday-Sunday there, too, because the drains he had to wash daily. It was possible to entrust the duty of doctors, but yet explain what drainage where installed, what how to wash — easier. And here you stand in the morning on authoritative medical rounds in intensive care and skin feel dissatisfaction with the fact that he is still a patient here, how much money it took…
I had to ask you where to put it. In the press writes that some hospitals are “unpromising” take out the gate, on street benches.
At such moments I do not know what to say. The chief our tried to transfer the patient in one rehabilitation center to another. But it drains in the stomach are “dirty” discharge, and rehabilitation centers take only unproblematic. Later put the patient in a private rehabilitation center for 70 thousand rubles a week. Relatives just for two weeks was enough money, then took him and nursed at home.
I don’t understand why the doctor put in this position. Is it my business to count how much is spent? We have medicine is declared as free. The patient went into a state institution, it should be treated. And the doctor should not play a role — he or oligarch poor pensioner.
With the patient what happened?
He has recovered, he’s fine. Sometimes with his son.
Scenario military-field medicine, when the doctor really decides who to treat and who not, because the resources are not enough at all, the real today?
Real. Often it relates to the lack of necessary antibiotics. And the doctor in the case of patient complications and may even punished “for failing to meet standards”. But at all desire it is impossible to comply with them. For example, we have developed protocols of antibiotic therapy in different groups of patients. It is for the prevention and treatment of postoperative infectious complications. If the patient came “sterile”, that is, in the last month before admission no treated, without any of the alleged infection, the use of “simple” antibiotics.
But often there are cases when a person is standing drains, flowing bile in the analysis — the “evil” bacteria. In this case, require stronger antibiotics. It’s all there in the protocols, before we follow them. And now ask elder sister the drugs and get the answer to: what antibiotics gave the pharmacy the and treat. Or, rather, pretend to treat. Because current antibiotics are mainly represented by the penicillins, as during the great Patriotic war.
On Friday, the weekend will prescribe the patient medications. Monday’s coming — the nurse said that did not, another, too, because I had only two days. Sometimes such messages hands down.
But what then do?
We go to knock. It happens like this: call farmacoterapia, he assesses the situation, calls up the pharmacy, finds out from the drugs, making a record. Then populated with the destination Protocol of the drug, signed by a Commission of three. All must endorse the chief physician. Run to the doctor, don’t always catch it in place — after all, he had other things to do. Sometimes two or three times running or resident will be sent. But let’s say lucky: the doctor is in place, signed — rushing to her older sister, and she was in the pharmacy with the paper. And there: “do Not give you want. We do not have”.
Several times I came to the pharmacy and was asked to write on demand that gave so much, in larger quantities is denied. From there on its hind legs: “Why should we write?” “I must medical history to indicate why this drug I was prescribed for five days, not ten.”
When people start to talk something possible to achieve. Understand that the pharmacy holds medicine too not from good life, and from their lack. If your patient I the drug knocked out, probably someone else has not got. But the search process may take a few days. And there are times when a powerful drug is required right now.
What antibiotics! The disruptions went with saline. Even in 1990-e years I do not remember that I had to save saline or glucose. This is the cheapest and most basic medicines. It is believed that the antibiotics should enter the drip. For this, the drug is dissolved in saline. But this method is almost forgotten. In the absence of saline sisters put injections of medicine into the muscle or simultaneously injected his syringe into the vein. So bad supply as it is now, never before in the Institute was not.
Relatives asking to buy drugs?
When does the hopelessness, of course, looking at relatives and trying to figure out: can we ask them or not. Some will say: tell me what you need and I will get it. Yes, it happens, and so get out of the situation.
But the relatives of morally difficult to ask for drugs, especially expensive ones. You can’t guarantee that it will absolutely help. After the appointment of a particular drug in a particular situation — a condition necessary but not always sufficient for treatment. In addition, not all can buy.
Professional forums doctors often say they prefer not to name patients the material difficulties in the treatment. Why?
I’m afraid. Then I realize you can’t judge their colleagues. Because an appeal to the relatives, asking about buying drugs are not legalized in hospitals, and in the case of complaints is to blame the doctor. So I choose to try to ask or pretend to treat. To pretend, it is necessary to acquire a shell of cynicism. I have it in my life failed. Patients need love. This is a necessary condition of the doctor. Hippocrates said: “treat the patient the way you would like them to treat you in time of sickness”.
Will start to wriggle and Dodge — the patient is immediately intuitively understand and begin to contrive a situation which does not exist. So I stand by the position that it is better to explain things as they are. If the patient feels that he is telling the truth, he’s going to cooperate with the doctor. Only together with the doctor, the patient can overcome the disease.
Medications that often are you in short supply, expensive?
The concept of “expensive” for each sound. Someone and 10 thousand can not afford, and for someone and 100 thousand not a problem.
On average how much?
For example, very often our patients require albumin. After major resections of the liver there is swelling, bad heals. An average of 100 milligrams 20-percent solution are 5-6 thousand rubles. Need 6-10 bottles depending on the condition of the patient. It turns out that at least 30 thousand.
Your colleagues say that a deficit of only — in almost all hospitals. Maybe it really is not enough money, not the government allocates sufficient funding?
And doctor do with it? It is, in General, the function of leadership is to go to the Ministry of health, the state Duma, to speak about the revision of the value of quotas, which the state finances the treatment, put the question to the insurance companies to raise tariffs.
We at medical conferences in the Institute, the doctor says that the work is progressing well. Mortality and postoperative complications are reduced for two consecutive years. In a semiannual report, it was stated that the number of complications in cardiac surgery is zero percent.
This is a good statistic?
Beautiful. All the world’s leading centres must envy us. But seriously, there are international statistics of postoperative complications in each area of surgery. These figures sound like fiction. There is no surgery without complications.
And in addition to the progress reports any problems are discussed at medical conferences?
For example, how to reduce the waiting list for treatment in the Vishnevsky Institute. One of the Deputy chief physician suggested once a week to meet with the heads and to delete some of the patients from the regions. Perhaps someone has seen progress in Oncology, while waiting, and surgery are contraindicated, someone operated on in other institutions, someone did not live, etc.
I spoke at the conference: maybe go the other way and, conversely, to increase the capacity of the operating? Let them work in two shifts. In addition, in patients ‘ interests to reorganize the operating unit. Sometimes there are added an emergency.
Now ten offices in seven surgical tables. This, in General, is not enough. Emergency operating there. At the Institute for operations is long, you can go for five, and sometimes for 12 hours. In these conditions, hard life must be for patients who develop postoperative complications. No less hard and their doctors. Try to imagine throwing the doctor when the patient should immediately operate, and there is no place.
Recently brought a patient from the 2nd abdominal Department for elective surgery. And suddenly it turns out that in intensive care the other has already been operated patient opened massive bleeding. The doctor is running, the operating wheeled out the gurney with the patient is prepared, sends her back to her room. Time to file an emergency. If the planned operation has begun, to stop would be impossible. The patient with the bleeding wouldn’t wait and just die. There were cases when in similar situations had to operate directly on the intensive care bed. It is an additional risk for the patient. The surgeon there is insufficient lighting, difficult to access. In such moments, you feel creepy.
If it’s so critical, why not expand?
Here we have with colleagues the same question. Management believes that it is too expensive. I’m afraid that the health Ministry did not give a sufficient number of allowances to conduct operations, the cost does not pay off. Well, do not give quotas, you can work on the MMI system (mandatory medical insurance). There is also LCA (voluntary medical insurance), etc. That is sources are. However, to work with insurance companies, attracting the channel of DMS, the service: renovation, modern and comfortable chamber, the provision of consumables and medicines.
We have under the previous Director was renovated first and second floors. They are considered administrative. With the arrival of the new Director began a new repair. Beautiful, majestic, tasteful. The walls are laid out marble tile with the logo of the Institute — “IHV”. However, in February of 2018, we were awarded the status of National research centre. Apparently, soon to be tiles with the new logo.
But the administrative body — the face Institute?
I always thought that the face of the Institute of surgery — surgery unit. We have seven existing operating today, one in poor condition. From the ceiling intermittently falling plaster on his head. Sometimes during operations. Well, that patient yet did not fall. Tools for surgical interventions under video-endoscopic control (laparoscopic surgery) is worn, not updated. Even a simple laparoscopic cholecystectomy in these circumstances becomes dangerous for the patient and stressful for the surgeon hours action.
Not purchased any disposable stapling devices, no magazines with staples for reusable suturing devices needed during operations on the esophagus, stomach, intestines. You have to work at either the old antediluvian devices, developed in the middle of the last century, or manually. Well, that at least the thread is there.
One of the operating just be idle. And operating room of the purulent surgery Department of can be taken to different studios to shoot films about the war — so everything is old and worn out. A great repair is made in the irradiators of the Department of x-ray surgery. Its Director had previously worked with the current Director of the Vishnevsky Institute in Bakulev center of cardiovascular surgery.
Your open letter is being discussed in social networks. The leadership of the Institute hinting that this is all a struggle for power. And you went to war to occupy the chair of chief.
I wrote a memo to the Director NMISA academician A. sh. Revishvili with suggestions on optimization of work of the institution. One of the items offered to dismiss the current chief physician. The reasons for the inefficiencies. And consider my candidacy for this position. Decide is offered by secret ballot at a meeting of the heads of departments. You know, it was kind of a joke. I am the Clinician to the bone, held in the profession. Administrative work is for me uninteresting. But then I thought who if not me? Perhaps, and the chief physician.
In a personal conversation with the Director directly suggested it. At the same time stressed that I was not interested in the position, and credentials. I will decide what is needed for a surgical service, because I know her logistics. What’s wrong or materialistic in this sentence? Failed — fired miserably in a few months! Isn’t that right?
To me the Director during the audience, which were announced claims on shortage of consumables and equipment said, “And where I get all the money?” I said, show me the financial flows — and I’ll tell you where to take it.
Do you have specific suggestions of the search of scarce resources?
We must first see whether such a small budget the funding of the Institute to a global shortage. The next step is to calculate the cost of treatment of each patient group in each industry. Then, based on these numbers, to build a business plan. One gets the impression that no one does.
It is considered that almost all departments in the Institute unprofitable unprofitable. But we have a theme — reconstructive surgery. After gallbladder removal patients are often damaged bile ducts. This can be corrected — again surgically. It happens that arise in the ducts of the scars. With the help of special drainage ducts to dilate. The government allocates the quota for this treatment in 100 thousand roubles. But the latest purchase of drains was in December 2017. By February they ended. Since then, nobody buys them.
Imported, the most expensive drainage costs 14 thousand. Some need two. The average stay in hospital for three days. Given that a bed-day is 2500 rubles, for three days of hospitalization are 6500. In the end, the cost of the maximum — 42 thousand rubles. Nearly 60 thousand is the health facility. But when you consider that many do without hospitalization, then the circle turns very much, it’s called profit. Some patients who buy tubes. It turns out that the drainage paid twice by the patient and the insurance company.
Another example. Taken at the Institute of Oncology. Wonderful doctor, knowledgeable oncologist. Medical institutions and even commercial clinics is advantageous to perform chemotherapy on channels of obligatory medical insurance. It is well paid. But our administration believes that it does not profitable. Chemotherapy is conducted, we only charge. The average course costs 70 thousand rubles. The course is held once a month. So consider! Of course, many people can not afford it. Institute that loses patients and money.
You went to the office of the President and the Prosecutor, and audit chamber. There are answers?
From the President’s office redirected my letter to the Ministry of health. There came a lady, the management gave her a tour of the renovated floors. In clinical offices it never came. And we waited. Response from the Ministry of health has recently come: “According to information received from Federal state budgetary institution “Institute of surgery named after A.V. Vishnevsky” of rmph, the facts stated in your appeal, not confirmed”. From other departments yet nothing came.
After the publicity of the administration of the Institute has already made some steps: on the academic Council, the Director announced that the planned purchase of the new Da Vinci robot, CT and magnetic resonance imaging.
Why no one except you from the Institute did not sign the letter?
I decided not to. One easier. I will raise now a revolution, inspire people to feats, but will not go as you want. They look me in the eye and say: that did not work, fired. We have young men: 40-50 years, the breadwinners for their families. Well, why should I shoulder the responsibility for the fate of colleagues? Hard to answer for those whom you have tamed.
Even now I’m afraid someone at the Institute to stop, to greet. At conferences I try to sit separately from the others, so that people do not fall under the suspicion of the administration in the relations with me. But a lot of people support me. In the corridor meet, you whisper, well done!
Hope for change for the better, of course. Now get letters from doctors from other hospitals. Write that they have almost the same. But they reconciled. Ordinary people have ceased to believe that they are anything significant depends, that they can overcome the system.
And you believe in it?
Believe it! I am a maximalist. If I did not believe, did not start this fight. Don’t think I’m so brave. Just have a spare parachute. In December I turn 55, I can retire. For myself I am not afraid, just leave the medicine. Maybe for those who remain at the Institute, something will change for the better.
PS We called the office of the Director National medical research center of surgery im. A. V. Vishnevsky Amiran Revishvili. However, there declined to comment.
In turn, the physician NMISA Fyodor Semenov has informed Olga Andreicheva that the administration is preparing a lawsuit against her in court “for libel..,for trying to denigrate the activities of the lead Agency surgery in the country.”
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