Day 71, Choices, we all make them every day. Some more trivial than others, ketchup or mustard, drive or take the bus, one more drink or not. In medicine no matter where you are choices are crucial. However many would argue that it is becoming less so in the UK, at least for the individual doctor. The government tells you what you can offer, and NICE tells you what the best medications are. When you prescribe a drug there are usually local guidelines which mean it can often be a tick box decision.
In rural South Africa things often get more creative. It is almost paradoxically so as our repertoire of medications is so much narrower, but you have more free reign to prescribe. There are a number of factors which influence this creativity. Perhaps most commonly is the lack of stock, you then have to start thinking about the best alternative ways to treat people. You try and follow best practice guidelines but this is often not possible.
At weekends there is no pharmacist available, and as the doctor on call you will have the keys for pharmacy. This means that when I want to prescribe medications to take home it is often limited by what I can actually find, there is not always a functional catalogue system. Whilst playing pharmacist you also have to try and find medications for the wards as they may not have restocked prior to weekend. Again when you can’t locate the stock you will have to get creative otherwise the patients won’t receive any medications.
Perhaps the most difficult choices I have to make in Mseleni are the ones where I know the resources are limited and I have patients competing for them. Do I take a chance and transfuse the guy who is having a bleed or do I try and keep our emergency blood supply in case there is an obstetric emergency? I suddenly have to take into factors such as their HIV status and their relative chances of a positive outcome, playing judge and jury.
The temptation, and our training is to treat the patient in front of you. Here you have to think about the bigger picture as well. Today I decided that I wouldn’t send a young guy with a neurological problem on an ambulance for a CT scan because it would tie up the only available ambulance for emergencies in the region.
Having to operate with the rationing of resources in mind is not the burden it would seem but almost empowering. Though most of the decisions are hopefully correct ones, taking a chance means inevitably there are times where I’m getting it wrong. But here the only really unforgiveable decision is the one not to make a choice at all.
Obviously it's the ketchup! Duh.....
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