The ethics of inadequacy

“I think we should transfer the patient to CT with capnography”

“Excellent Idea” agrees the registrar

Call consultant.

“Unfortunately we do not have capnography on our portable monitor, we know this is not ideal.”

I transport the intubated patient without this.

This is a decision we are faced with everyday in any stretched healthcare system. To continue operating with resources that are inadequate or to stop doing what we are doing entirely?

As an interloper from a mildly stretched healthcare system into an extremely stretched one I can see the inadequacies more acutely and feel them more heavily.

In that moment, the decision was not a particularly difficult one. It was me or one of my colleges that needed to go. The patient needed the scan (which turned out to be diagnostically crucial). They are busy doing important work, and although in many many ways they have superior skills than my own, in this case, after being drilled all of last year on the rigorous first-world anaesthetist approach to caring for an intubated and sedated patient I felt I would be a safe option.

But more fundamentally, should I be here at all? Last year, at a recent training day aimed at Emergency doctors looking to work globally they suggested frequently that if you cannot work to the standards you work at home, you shouldn’t work in that location at all. This goal is lofty and idealised. It also ignores the compromises we have to make at home.

In the intensive care unit I worked at previously, the ventilator units were not MRI compatible. This meant that if an intubated patient required a MRI they would have to be transferred to another hospital, this inevitably led to delays. This is a healthcare inadequacy, just of a different scale. If in Mitchell’s plain, South africa you need an urgent CT head, you will be transported in less than ideal conditions, in Worthing you need an MRI you will also have less than ideal conditions.

This are two trite examples, however the point remains. Our reaction to system inadequacies is the same in any situation. You pause, think about the best option available, then you undertake the option that is the best for your patient in the circumstance you are in.

I must remember to continue to pause.