Death as learning
Yesterday was a mortality audit. Sitting through discussions on why the patient died. A pregnant patient who was kept in a government hospital for hours with seizures and then at last minute referred to higher centres for care. Being brought unconscious, baby In the womb about to die, mother too in the last stages, with extensive pneumonia and sepsis, the team had to decide between life of the baby or mother. Taking risk a healthy baby was delivered and the mother pulled through fine too. But over next 24 hours mother succumbed to the extensive pneumonia and sepsis that had set her on a downward course, due to delays in reaching the hospital. A not so uncommon event in rural India or the invisible Bharat, though these are not part of the visible India or Bharat. Many questions were asked and reflected on. What could have been done, was there anything more that we could have done, despite the delay in reaching the institution etc. As I was listening to these conversations, a few thoug