I.C.U. founder mourns "tragedy" of its undoing
The man who established the Intensive Care Unit (I.C.U.) at Moto'otua Hospital, Dr. David Galler, is mourning the "tragedy" of its abandonment and the rise in deaths of critically ill patients.
The former Head of the I.C.U, Ma'apupula Dr. Dina Tuitama, resigned in April this year.
The unit, formed by a team led by Dr. Galler in 2015, became the hospital’s first specialist, six-bed I.C.U.
By the time of Dr. Tuitama's resignation, the I.C.U had been effectively disbanded to become an open (or generalist) unit.
Prior to its establishment, Dr. Tuitama said an audit in 2012 found a mortality rate of 82 per cent among ventilated patients in the I.C.U; a year after the new I.C.U. was established, that mortality rate fell to 19.7 per cent.
She told the World Congress of Intensive Care last month that since her departure and the unit’s reformation, mortality rates have shot up to 31 per cent in May, and 47 per cent in July.
Maintaining the unit, Dr. Galler told the Samoa Observer, was critical to keeping patients alive.
“The outcomes, particularly for critically ill infants were outstanding,” he said.
“It seemed to all of us there was a group of people for whom we could do quite a lot better, and particularly because they were infants and children.”
Dr. Galler is an intensive care specialist who has worked for 30 years at South Auckland’s Middlemore Hospital.
The Government helped fund the new I.C.U. at Moto'otua Hospital but he also drew no salary and contributed his own money to its creation.
The I.C.U. he helped establish in 2015 was built to care for infants, children and young people who were dying of acute reversible disease, illnesses that are “normally quite treatable,” he said.
“One of the things I find deeply saddening is that the decision makers in the organisation didn’t appear to value that further and didn’t support that service with the personnel required to keep it going,” Dr. Galler said.
“Despite lots of conversations, requests, letters, they didn’t respond in any kind of positive way to support that service or to learn from the success of that service..
“It’s a great disappointment actually that that happened and I think ultimately it’s a tragedy for Samoa that this has happened.”
Dr. Galler involved medical volunteers, doctors in New Zealand and Australia over the phone using a TeleHealth system, and at one stage nearly had a diploma in Intensive Care Medicine established at the National University of Samoa, all to make the I.C.U. a success.
But before long it was clear the new unit was not fully supported by the health service leadership, he said. The bulk of the work to keep it going fell to just a few people who eventually became overwhelmed by the burden and left.
Dr. Galler would not name the people he considers having failed to take the ICU seriously, but instead said that “they know who they are.''
Maapupula, Dr. Galler and their small team of mostly young female doctors and nurses faced unsupportive leadership, poor procurement leading to medicine shortages and even staff.
Asked why the leadership didn’t take the lifesaving unit more seriously, Dr. Galler said he has thought deeply about it a lot.
He has several theories, including even blaming himself and the team for not communicating their value clearly enough to the health service leadership.
“I have thought if the decision makers weren’t able to jump on a plane and go to New Zealand or Australia when they became unwell, maybe that support would have been greater,” he suggested.
“They can get on a plane and go to Australia and New Zealand when they get worried about their own health or their families health but for the vast majority of Samoans that is not an option, and I am anxious that actually ordinary people are missing out as a result of those decisions.
“Maybe there were some issues around people, I have wondered that. This service is run by young women, the decisions were made by old men.
“I wondered about some of those hierarchical issues around Samoa that perhaps I don’t understand as well as you.”
But regardless, Dr. Galler said, it is a tragedy to lose the I.C.U. in the life-saving form it had.
One of the reasons the I.C.U. mortality rates are rising, Maapupula says, is that the I.C.U is no longer a closed, specialist unit. That means only, or nearly only intensive care specialists are treating the patients in it, rather than a mix of doctors from around the hospital.
In an open, generalist setting, a paediatrician and surgeon might care for a child requiring surgery in the I.C.U. But data has proven that outcomes for patients are worse under this model because it becomes chaotic, Dr. Galler said.
But the better option, the closed setting, is a high trust model that requires excellent working relationships in the hospital.
“You are relatively short staffed, compared to NZ and Australia, and the workloads are very high,” Dr. Gellar said.
“Your young doctors work very hard.
“We tried to find a middle road where there was one or two I.C.U. staff who were dedicated to intensive care but actually there was quite a lot of input from the speciality areas who provided a lot of support, so you didn’t end up burning out one or two people, as has happened here.”
That model has been eroded, the doctors said, and other young doctors like Maapupula are leaving the health service burnt out.
"This is a great loss for the country," Dr. Galler said.
“To see people leave the service because they are not supported, because they are not listened to, because they don’t have input into how the service changes with time or can improve is very disappointing and a great loss for Samoa too,” he said.
“If the people who ran that service were more attuned to the kinds of input some of those young people could provide, and listen to them a bit more I think the service would improve enormously.”
The specialist said the Ministry of Health needs to take a serious look at the I.C.U.’s demise in the “cold light of day” to understand what went wrong and to try and revive it.
It is possible for Samoa to have excellent treatment for incredibly ill people, even within the confines of its context with less resources or accessibility to medicine or expertise than other countries, he said.
But right now, there is a lot of emotion around the issue which needs to pass, he says.
“I think there is an opportunity at some point for there to be a more formal look at what happened with regard to that service.”
“We need to step back from all of that and at some point step back and review this and think about it in a clearheaded kind of way to try and learn from this whole experience and decide what the next step should be,” he said.
The Ministry of Health did not respond to a request for comments.