Giulesti and the human error

Day 6 and there is less and less to be seen in the press (both international and Roumanian) regarding the tragedy at Giulesti Maternity Hospital. There is one article however, an opinion in the Bucharest Herald I'd like to share with you. This is written by 'Maxy' on the subject of and entitled 'Human Error':

Over 90 per cent of aircraft accidents are caused by human error. We are used to hearing the verdict: ‘Human error!’ This shows we are all capable of mistakes in tense moments, even if we are well trained or highly specialized. But those are errors caused by stress and the pilots making mistakes put lives at stake.

In the case of the conflagration at Giulesti Maternity all evidence shows it was also a human error. Another kind of error. At stake – lives of babies. One based on disinterest, superficiality and stupidity.

Manager Marinescu has been suspended until inquiries are over. Light punishment for a man who patronized the entire hospital. The one who picked a firm, having an apartment at its headquarters, to deal with the air conditioning aparata. A firm that closed its activity on Thursday to escape (they believe) from prosecution.

In July, the firm carried the latest checks on the apparata and everything was OK. We can all see what happened. The same manager Marinescu seems to be more preoccupied with his private clinic than with the maternity hospital. Or more preoccupied with becoming famous – he is the one who helped 67 year old Adriana Iliescu give birth to a child in 2005. Has he ever checked on how nurses are doing their jobs?

There are other guilty characters as well. I hope the prosecutors will charge everyone responsible, but I believe one person in particular should be hanged. For real. I am speaking about the nurse in charge with guarding the childrens' reanimation ward.

She has no excuse whatsoever for leaving the babies alone for more than 20 minutes. It is said that a celebration on the occasion of Saint Mary was taking place somewhere in the building and she had been there. Even is she wasn't, even if she went to the toilet for 20 minutes, it is inexcusable. Somebody should have been in her place with the babies as they were in trouble anyway and needed supervision.

Videos show nurses running away when the ward was on fire. Temperatures increased up to 200 degrees Celsius in the room. Just one person, the above mentioned nurse, haved the electronic card to enter the ward. How could this happen in 21st century Romania? Was this manager Marinescu’s decision?
Hundreds of questions are running through my mind.

I wonder what goes through the mind of that nurse? Human error – should we accept that? It is an ‘error’ and so much more. Is it also ‘human’?

Maxy

Several comments from me. The first to blame is the minister of health, Attila Cseke, who ignored calls for more staff at Giulesti. With zero experience in the medical field, he was named Minister of Health by the UDMR becasue there was noone better than a notary for the position. We know that a demand came in February of last year which sat on his desk for months and was recalled in March 2010. The demand was never passed on to the ministries of finance and labour and thus, the help never came. Cseke is responsible for the dire straits within the Roumanian health service today. Noone else. Second to blame is Oprescu who knew perfectly well what was going on at the hospital too. He knew about the ancient electrical system because he had received memos and he knew about the appalling staff shortages. Next on the hitlist is, as Maxy says, Marinescu (see Adriana Iliescu story here), who, in my opinion deserves a fate worse than death for his indifference and cost saving decisions that caused this terrible tragedy - he organised the a/c installation, he fudged and fudged and fudged and whilst the hospital under his care slipped further into the bottomless pit of cuts, shortages, blatant lack of discipline and total unprofessionalism, he was making a fortune at the Marinescu Medical Centre not far from Sos. Kiseleff... that is what I would call inhuman.

(Photo: Adevarul) Marius Savu (left) has a lot to answer for. He is a dithering moron, an incapable bureaucrat with zero medical experience and, unfortunately for everyone, the overseer of hospitals under the Town Hall's jurisdiction. The man is a liability and even a lobotomy wouldn't help matters for there isn't much matter there to work on. Two gaffs - the first to suggest transferring the critically ill babies all the way to Israel - thank God the professional brains had arrived and were able to advise against it, gently but firmly - and the comment that even had there been smoke alarms it wouldn't have helped. What kind of an imbecile says such a thing? Furthermore, the Israeli doctors City Hall 'invited' to Bucharest to assist in the babies' treatment were not even formally introduced at the hospital... what a slap in the face for such professionals.

Next for the firing squad, Mirela Ranga, medical director, the idiot who said she knew perfectly well there were no smoke alarms or fire sensors but that 'they were not mandatory'... on an ITU where there were helpless babies, oxygen tanks and expensive equipment... and finally, finally Florentina Cârstea (see here film and opinions from Observator) the 'nurse' on duty that night whom, I hope, will never have a peaceful moment for the rest of her days. Leaving the babies not for 20 minutes as Maxy writes, but 40-45. She lied, she covered up, she was the only one with the swipe key and then when she finally arrived at the scene - too late, by the way - she was as good as useless. Maxy says "I wonder what was in the mind of the nurse". Well, first, Maxy, she wasn't just a nurse but the assistant chief of the ITU and secondly, nothing was in her mind because she is very clearly completely empty-headed - much like the rest of the management team. That Ranga - don't even get me started. And Ranga was her immediate boss.

Here is the chart rundown of incompetents, the hit list of those so grossly negligent and irresponsible. Every single one of them should be removed from their posts effective immediately, have medical licenses (if they have them) withdrawn never allowed to practise again, while Marinescu, Ranga and Carstea should be thrown in jails for crimes of incompetence leading to manslaughter. It was manslaughter. There is no other way to look at it. Five babies burnt to death horrifically and six still fighting for their lives. Had it not been for the father who broke down the door and the firemen who got to the scene just afterwards, ALL eleven babies would have burnt to death. The number of babies is not important. The value of human life is. Human error? No. It wasn't. It was human incompetence and inhuman indifference that murdered these little mites and those cited above should be made to pay like noone has ever been made to pay for anything. They should be strung up for all to see, given to the families to rip to shreds and then fed to the general public who will, I am sure, finish them off. Such indifference, negligence and incapacity should never come to light again at the expense of lives - things should never have gone this far. That is ultimately Attila Cseke's bag and his resignation, though not a cure for the terminally ill healthcare system, would be a sign of humble conscience, an admission for his repetitive blunders and an excellent place to start.

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Later: I have just read this article from Nine O'Clock and having thought I couldn't be more appalled...well, it turns out that I am. Firstly, PM Boc states, "“We will look upon the matter in September and try to allow supplementation of jobs in health.” The millions of euros he allocated to his ministers by SMS and the 125 million euros generously pledged to the republic of Moldova by Basescu are flagrant examples of money being spent on non-priority issues - all these euros should be put to good use in the health system, especially considering the importance that the government place on the loss of the babies - families were offered compensation of 5 million LEI for each baby who had died. Inadmissible. Such insensitivity from the PM as well as the President who only thought to speak publically on the tragedy as late as last Thursday.

Nine O'Clock reports: 'In a press statement on Saturday, Mayor Sorin Oprescu, also a doctor, said that, apparently, the medical personal was not “where they were supposed to be at the time and the guilty ones will have to pay for the tragedy. There is no excuse in this matter, and no getting away with it,” Oprescu told Mediafax, who also added that “lack of discipline is a recurring state of fact in local hospitals.”' Yes, also a doctor - a heart surgeon, I believe, who is now Mayor of Bucharest. What is a surgeon doing in such a position - and being one, he should well understand the gravity of conditions within the health system.

The article goes on to say that Oprescu visited the hospital and 'also said renovations will start as of today to help bring the affected wards back to functional status. The first estimations show a EUR 1M initial sum will be needed for mending affected infrastructure and damaged air conditioning installations.' Does he mean to repair the ancient, malfunctioning a/c system on ITU rather than install a new one? And look no further than Gândul's breakdown of costs yesterday on the price of fire safety equipement - 564 euros. Even with a new a/c system, new incubators and a paint job, I do not know where he pulls a million euros out of the air...he clearly believes that one does not understand the value of money. Incubators will certainly be donated from well-meaning foreign associations, of that, you can be sure. The tragedy at Giulesti has touched the heart of everyone within the international community.

(Photo from Sheba Medical Centre home page) And what of these Israeli doctors, then, that have caused a bit of a heist? Unknown? Un-named? Not at all. They were from Tel Aviv University and one of them was none other than the reknowned specialist Dr Josef Haik. Dr Haik, MD, MPH is a plastic surgeon and Director of Tel Aviv's Sheba Medical Center Burn Unit. Despite the fact that the doctors were 'invited' by the city of Bucharest, Marius Savu omitted to communicate their arrival to the director of G.Alexandrescu hospital, Dan Enescu and so, when finally they got there, they were apparently not allowed anywhere near the babies because noone knew who they were. That's some way to treat brilliant physicians from abroad who have come to give their expertise to alleviate at least a little of the babies' suffering. Bravo. I bet the doctors did indeed wish to take photos - they'd never seen anything so shocking in their lives... but as these brilliant (yes, brilliant) doctors weren't allowed to approach the babies, they could be of no help. Dan Enescu, too proud to accept assistance from those who knew better - far better. Here are some photos indeed taken by the doctors during their time at Giulesti - they were not used for some foul motive, as you will see via Newshopper.

The final line pierces my heart: "According to media information the premature babies who are still alive are a case of medical investigation, as world medicine has never encountered such a severe case of infant burns." How dreadful. How absolutely horrifying. It's obscene. See what you have done, you people responsible for the tragedy. You have created such suffering it's never before been seen in world medicine. I can't even begin to imagine the state of these tiny, helpless babies in such agony...and when I try, I am afraid to turn out my nightlight to sleep.

Comments

[sairj]

Dear Aura, I wanted to blog your link to show some of the goodness that is coming out of this horror - the fireman from yesterday is still in my heart - but the link is kaput. Can you send me anything else? Or put it here...

From every horror we see a sliver of humanity. Not enough, but a little. It's enough to believe we should still be fighting, that it's worth battling for. Your ESPERE, the lovely fire fighter...they are worth tons more in gold than the impotent and indifferent worms of the Ro govt and those within the accutely-known failed Giulesti medical system. Tons more.
Thanks for posting, Aura xox

[aurab]

It may not have much in common with yr article Sarah but I felt a big emotion seeing that there are some people thinking how to help..
One of my colleagues from ESPERE thought of giving psychological assistance to the people involved in the Tragedy.
Here is the article from
http://www.paginamedicala.ro/stiri-medicale/Psihologii-ofera-gratuit-terapie-suportiva-cadrelor-medicale-de-la-Giulesti 8763/

"Cadrele medicale direct implicate in tragedia de la Maternitatea Giulesti din cauza stresului si a presiunilor mediatice ar putea fi o bomba cu ceas. Asta pentru ca prin natura meseriei acumuleaza o serie de frustrari si sentimente de vinovatie legate de cele intamplate. Mai mult decat atat, puse acum in fata unui asemenea dezastru, nervii oricat de tari ar fi cedeaza.

"Daca nu li se aplica terapie suportiva risca sa ajunga la stari conflictuale foarte puternice si sa aiba o constiinta foarte incarcata. Cadrele medicale au o profesie foarte dificila, supusa stresului permanent si riscurilor emotionale. Se expun la boala, suferinta, dar si presiune sociala. Din aceste motive au si un sentiment de responsabilizare foarte mare", a specificat psihologul Bogdana Bursuc, psiholog la Mind Institute Bucuresti.

In opinia specialistei, medicii si asistentii medicali se simt mult mai responsabili decat electricienii sau alti lucratori din sistemul sanitar.

"Ar avea mare nevoie de suport psihologic tot personalul implicat in tragedia de la maternitatea Giulesti", a conchis Bogdana Bursuc.

Psihologul clinician Daniela Neagu, presedintele Asociatiei Romane pentru Terapia prin Jocul cu Nisip, a luat initiativa de a oferi terapia suportiva atat pentru pacientii afectati de incendiul de la Spitalul Panait Sarbu din Capitala, cat si pentru personalul medical, aici intrand nu doar asistenta medicala de pe tura din acea seara, ci si ceilalti angajati ai spitalului care au lucrat in teribila noapte.

"In acest moment suntem 5 psihologi clinicieni si terapeuti dispusi sa preluam in asistenta gratuita familiile afectate, precum si personalul medical. Le vom oferi gratuit terapie suportiva", a precizat Daniela Neagu.

Detaliile legate de aceasta initiativa, precum si modalitatea in care cei interesati pot sa se alature psihologilor, parintii le pot gasi aici. Cadrelor medicale care doresc terapie suportiva PaginaMedicala.ro le sta la dispozitie cu contactele psihologilor implicati in aceasta initiativa.

Danielei Neagu i se vor alatura pentru asistenta (psihologi asistenti) si absolventi psihologie 2010 si studentii din grupul de practica clinica, studenti in an terminal la psihologi.

Pana acum, ideea Danielei Neagu este salutata deopotriva de medici si psihologi.

"Este laudabil ca s-a gandit sa ofere asemenea suport", a afirmat dr. Radu Mihailescu, medic psihiatru la Sp. Obregia. La fel a spus si dr. Albert Veress, presedintele Asociatiei Balint din Romania, precum si psihologul Bogdana Bursuc.

Grupurile Balint care la inceput au fost create pentru medici ar putea fi si ele o solutie suportiva pentru cadrele medicale bucurestene. De altfel, Asociatia Balint din Romania s-a aratat deschisa la a-si oferi serviciile cadrelor medicale de la Giulesti afectate de cele intamplate.

"Daca isi exprima dorinta si sunt de acord, li se poate face terapie suportiva. Nici nu s-ar pune problema banilor. Nu cred ca un balinitian s-ar gandi la asta", a spus dr. Albert Veress.

Orice varianta vor alege medicii si asistentii medicali care au lucrat in noaptea neagra la Giulesti, va fi in beneficiul lor.

Nu se stie daca in echipele de specialisti mobilizate de urgenta la Giulesti au fost sau nu implicati si psihologi.

"Macar cei pe care ii au spitalele. Nici nu cred ca vreunul dintre psihologii spitalelor s-a sesizat singur sa isi ofere serviciile in aceasta noapte teribila pentru cei afectati... dar desigur, sper ca de azi serviciul psihologic va fi disponibil in spitale. Iar psihologii din spitale ar trebui sa intervina de urgenta, sa mobilizeze la randul lor colegii din afara sistemului spitalicesc, sa creeze echipe, sa asigure cadre de asistenta in afara spitalelor pentru cei afectati", a spus Daniela Neagu.

In organigrama Spitalului Panait Sarbu figureaza un psiholog angajat si anume Genoveva Teleki, care ar trebui sa se ocupe de cazurile parintilor in discutie.

Cert este ca centrele de criza cu echipe mobile care sa ofere suport psihologic in spitale in Romania sunt rara avis, in timp ce in spitalele occidentale fac parte din strategia domeniului sanitar.


Autor: redactor sef Alexandra Manaila
Sursa: PaginaMedicala.ro