The hospital may be large but it has large problems.
If it were a "resource poor environment" I would forgive it if it did the best it could in the circumstances. But it has facilities on a parallel with anything in the UK or even better. The fundamental problem seems to be that nobody really cares about making it better.
Let's go through a typical resuscitation. Patient arrives at the door without warning. Eventually somebody looks up and opens the cage door, letting the ambulance crew in. After a while a doctor will wander over to ask what they're doing there. Then they will call "resus" and walk to the resus bays, hoping the crew will push the patient after them. Once someone has remembered to bring a bed in from the corridor they'll carry the patient onto it. Following a brief argument over who will take each role, the airway etc will be dealt with expertly by doctors with more experience in their internships than I can imagine on most UK registrars. However, once the drainpipe-gauge cannula has been effortlessly slid into place, the needle is dropped on the floor because leaving it on the bed would be dangerous. Now our patient needs a chest drain. "Blade please" and one is dutifully produced, but no handle so you just hold the blade in your hand. "Exposing" - what? Oh, the radiographer has marched into the next door bed and just zapped everybody's gonads: everyone there is wearing a lead apron but nobody warned the ten people round the other bed. Now our patient is stepped down into the sort of ITU bays - where they kick resus patients after half an hour or so. Not clear what's intensive about it though as nurses are usually nowhere to be seen in this area. They are more likely to be on a break, or chatting in zulu behind the desk ignoring the queue of patients, or singing hymns for half an hour every morning at the same time as handover so nobody can hear a word that's said. Certainly they won't be restocking the drawers or shelves or cleaning the pools of blood in the resus bays or covering up the patient who's dropped their sheet or asking why they're moaning with pain or keeping an eye on the one with the tracheostomy and bleeding face or keeping up the sedation on the guy with the head injury who's meant to be knocked out for two days but is now trying to pull out his tubes in every orifice.
Yesterday I asked them to do the observations they're meant to do one everyone who comes in.
"But we have doctor". Where? Oh, on this bit of paper I left on the desk without the patient's name and nowhere near them or the file. Right. So what's the blood sugar? "Should I do that doctor?" Yes good idea sister. Ten minutes later she finds the machine (hidden so it doesn't get nicked), right, so what's the temperature? No can do, we don't have any thermometers. Yes, really.
It's not just nine out of ten nurses who are pointless. This is a country with first world chronic disease, third world infectious and malnutritive disease, and the whole gamut of untreated AIDS. The doctors here have seen every kind of pathology you can imagine and they are expected to be able to treat all of it, in contrast with our one hour lecture on "malaria and other diseases". Some of them are pitch perfect every time. Others are hopeless. I have watched one registrar receive a patient, decide the endotracheal tube is too small, and spend twenty minutes trying to change it, demanding the bed be moved backwards, up, down, a chair fetched, a chair taken away, and shouting at everybody present because she can't do it, before deciding to give up, then trying to carry on with the rest of the resuscitation and finding the massive haemothorax. She was clearly inexperienced despite being notionally in charge, and had no idea how to control the room with the result that nothing happened. The next week she spent an entire Friday night shift sat in a back room, while the two SHO-equivalents spent the night resuscitating patients and I dealt with the rest. On the other hand, thinking about a different one now, nobody in the UK would do a thoractomy without their consultant breathing down their neck.
Case reports to follow.
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