Provincial cases show shortage of obstetricians not only problem
Written by Writer on Thursday, October 30th, 2008
Review emergency services / Provincial cases show shortage of obstetricians not only problem
Makiko Tatebayashi / Yomiuri Shimbun Staff Writer
The death of a 36-year-old pregnant woman who was denied treatment for a brain hemorrhage by eight hospitals in Tokyo points to various problems facing emergency medical care systems in large cities.
For instance, three of the hospitals refused to treat her despite their status as government-designated perinatal care centers intended to provide emergency care to critically ill pregnant women. Why did the hospitals, regarded as the last line of defense for emergency cases, fail to fulfill their duties?
The woman was taken to the maternity hospital she regularly attended in Koto Ward at about 7 p.m. Saturday, Oct. 4, complaining of a headache and nausea.
A doctor at the hospital determined that the woman was in need of emergency care and asked Metropolitan Bokuto Hospital to admit her. However, Bokuto Hospital refused because it had only one obstetrician on duty at the time.
The doctor contacted seven other hospitals in the metropolitan area, but all of them refused to admit the woman.
An hour later, the doctor contacted Bokuto Hospital a second time and managed to have the woman admitted. The hospital called up another obstetrician, who delivered the woman’s baby by cesarean section, and a neurosurgeon performed brain surgery on her.
However, the woman died three days later.
The nationwide shortage of obstetricians was clearly a contributing factor in this tragic incident. However, there are rural areas where the problem of people being turned away by several hospitals is rarely seen, even though the shortage of specialists is a more pressing issue there than in Tokyo and other urban areas.
In these rural areas, certain large hospitals are designated as last-resort facilities that are required to accept any patients who cannot be admitted elsewhere.
Urban areas have many big hospitals, but there is no specific rule about which of them is ultimately responsible for admitting patients. The situation often leads to hospitals refusing to accept patients because they assume another medical facility will. These hospitals apparently are reluctant to take final responsibility for such patients.
Rules to determine which hospital is ultimately responsible for accepting patients should be established.
However, it is impossible for a hospital to accept any and all patients in an area because there are limitations to each facility’s physical and human resources.
Given this, it is necessary to build a system with cooperation from local private practitioners as described in The Yomiuri Shimbun’s proposal for medical care reform published in the Oct. 16 issue of The Daily Yomiuri.
In Miyakonojo, Miyazaki Prefecture, obstetricians in private practice are expected to escort their patients to the local central hospital when requesting they be admitted for emergency care the obstetricians cannot provide themselves.
The obstetrician and doctors of the hospital then jointly care for the patient at the hospital. If more human resources are needed, other local private practitioners are called in.
A similar system under which local private practitioners and doctors from other hospitals are actively involved in treatment provided by an area’s central hospital should also be introduced in urban areas.
Local governments are expected to take the initiative in establishing a committee of hospitals, private practitioners and residents in each community and preparing an emergency communication network.
A system to cooperate among communities also is required to respond to a situation beyond the capacity of a single community.
The eight hospitals that refused the patient on Oct. 4 included Tokyo University Hospital, which has 44 obstetricians. Admittedly, the main reason behind turning away emergency patients is a shortage of doctors. But an increase in their number does not seem to solve the problem once and for all.
Take Tokyo University Hospital for example. The hospital has cited as a further reason for its refusal that all of the beds in its neonatal intensive care unit were occupied.
It is a vital task to increase the capacities of these and other units across the country and improve the ability to swiftly transfer patients who stabilize after treatment at the unit, to other hospitals. People must be made aware of the necessity for such swift transfers.
To save critically ill, pregnant patients, cooperation between obstetricians and other specialists also is necessary.
The Iwate Prefectural Kamaishi Hospital in Kamaishi, Iwate Prefecture, has only one resident obstetrician. The obstetrician and other surgeons work together to handle emergencies, such as excessive bleeding during delivery. To make the system work, the hospital regularly holds an exercise in which it calls up its doctors to respond to emergencies.
Bokuto Hospital is an emergency hospital with an emergency room that has the capacity to accept all kinds of seriously ill patients.
However, the hospital’s perinatal care centers refused to accept the woman without asking the emergency room if it could take care of her.
The episode shows a lack of communication among departments at the hospital.
The central government has developed separate emergency systems for pregnant women and other patients, but it needs to review the policy and create a unified system.
(Oct. 30, 2008)
