Indian healthcare needs Indigo treatment, ASAP!

12 Midnight, Delhi- A senior resident in gynaecology is putting in a Veress needle into the abdomen of an anaesthetised patient for an emergency laparoscopic surgery for a ruptured atopic pregnancy. She checked the spring action and the patency of the Veress needle, then, expertly, she applied two Allis forceps on either side of the umbilicus, stab incised the skin between the two Allis with a no. 11 knife, and holding the Veress needle like a dart, she inserted it through the incision. Shehas been working since morning on a 24-hour shift, managing the labour ward, emergency surgeries, and ward calls. God! She thought, she needed some sleep! 
As her concentration wavered, she felt a third click on the needle instead of the usual two, and to her horror, she had the confirmation that the needle had gone through a blood vessel, as she could see the blood on the syringe on aspiration. The keen-eyed anaesthetist saw this all, and immediately activated emergency measures. 

2AM, Mumbai- An anaesthesia senior resident is getting ready to anaesthetize a very sick patient for an emergency laparotomy. All parameters of the patient are off the normal limits. This is his 16th hour of a 24-hour shift in a busy hospital. He prepared the drugs, checked the anaesthetic machine for any leak, applied the monitors, and, with the help of his assistant, safely anaesthetised the patient with a rapid sequence induction, then quickly inserted an arterial line and a central venous line with the help of the ultrasound, and started a vasopressor infusion to support the unstable blood pressure.
 It's like flying a plane, taking off and establishing on the auto-pilot, he told himself for the nth time in his life, as he was injecting the Amoxycillin-clavulanic acid antibiotic and making some minor adjustments to the ventilator. As soon as he finished the injection, he realised the fatal mistake, the patient is penicillin allergic! Soon after, the blood pressure dropped, showing the tell-tale signs of an anaphylactic reaction, a very serious allergic reaction!

7.30 AM, Chennai- The nurse went to the patient in cabin 116, with a tray of drugs to be administered for the morning medications. The elderly patient had a stroke, is bedridden, and can’t communicate verbally. She readied the insulin pen to administer the morning dose of the long-acting insulin the endocrine consultant has prescribed for the patient. As she swabbed the skin on the patient’s belly for the injection, the groggy-eyed son of the patient, still half-asleep in a side bed, asked in a thick voice if that was insulin. As she confirmed, the son informed her that the night shift had already given it. Perplexed, she looked at the drug chart again; no entry had been made as administered! 

These are examples of what physical fatigue can do to expert professionals in healthcare. Critical incidents like these, and near misses, keep happening in innumerable numbers in Indian healthcare. These are not dramatic like a plane crash; There is no registry, no audit for these kinds of events, no root cause analysis, but punishment and blaming of individuals when these are found out, or swept under the carpet silently. However, the proverbial elephant in the room, human factors arising out of fatigue, is never addressed. 

Resident doctors and nurses work impossible hours in Indian hospitals! 16, 18, 24, even 36 to 48-hour shifts; doctors in higher training work even harder. They are also entrusted with high-level responsibilities of patient care. It is only their young bodies and the burning ambitions in their hearts that keep them going. However, the brain gets tired, and things happen sometimes, and at the other end of every failure is an unsuspecting patient, maybe demanding immediate, world-class healthcare that is available 24 hrs. You may be one of them! 

While the publicly funded, government-run healthcare is ailing and constantly struggling to keep up with patient loads, the private, for-profit healthcare is flourishing and rapidly evolving to be the mainstay of healthcare provision in India. Unfortunately, the underpaid nursing staff and the resident doctors’ workforce are often overworked and stressed to the breaking point. A day shift continuing to the next morning to cover for absent colleagues, a night shift starting at 2 PM or 4 PM, or continuing to midday of the next day are common. These work patterns put immense pressure on their health and make healthcare delivery prone to errors of judgment. This is the underbelly of our rapidly evolving healthcare industry, less talked about. 

From many points of view, and particularly from the safety perspective, healthcare is similar to the aviation industry. Small mistakes can cascade into greater tragedies! In the processes, there are many “points of no return”; Absolute surety about safety is necessary before these committed steps. There are safety drills, plans A, B, and C, guidelines, protocols, and safety checks, but everything needs alert professionals, professionals who have the scope to take proper rest after gruelling shifts. The aviation industry is strict about these aspects; healthcare is oblivious! In European countries, work hours are regulated by the European Working Hours Directive, which stipulates hours of rest after certain hours of continuous work. Encompassing all sectors, these are aimed at thecommon purpose of avoiding human factor-related mishaps arising from workers’ fatigue. 

It is in the news that Indigo Airlines is finding itself in a very difficult spot for not following the Directorate General of Civil Aviation’s orders about safe rostering of pilots and flight crews, which is directly related to passenger safety. The DGCA is waking up to its role as the regulator; the Ahmedabad crash was a rude jolt! Perhaps this is also the time health regulators in India wake up to concerns about patient safety and regulating the work hours of clinical staff.There is also a need for urgent change in the public and healthcare leaders’ views about work ethics and service delivery.  

Maybe the recently passed four labour codes, regulating work hours and flexibility, are a beginning?