For unfortunate reasons we had to visit the Zakho Emergency Teaching Hospital as a family member got sick. It was a matter of an episode of tachyarrythmia since this patient has a known paroxysmal atrial flutter diagnosis. This is a write-up of my short experience with the hospital, system and doctors as a doctor myself.
Organization
The organization of this hospital is very confusing, everything is scattered around without an apparent system and everything feels chaotic. This is especially true for someone who has never visited this hospital beofore. Imagine that, but also having to take care of someone who is sick; or worst - actually being sick. You are greeted by a doctor who quickly asks about your main complaints and then directs you to the most appropriate station: ECG, vitals, blood work or/and an admission to a hallway of beds. Upon admission you are suddenly greeted by a 2nd doctor who reviews your admission paper and takes further actions upon that. I must say though I was impressed by how quickly things were being done. However, that came with a cost of things not being done correctly and ultimately inefficient.
Medicine
The medical part of the experience was to a trained doctor in the ER awful. The following are, imho, errors in the handling of the patient and questionable medical decisions:
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Lack of a thorough history-taking and a complete lack of a physical examination. There were quick questions about symptoms of angina pectoris, which is the bare minimum, allergies to medications and past medical history. Other questions necessary for an understanding of the patient and his/her symptoms, i.e. the SOCRATES acronym, were never touched upon. This led to unnecessary diagnostics (see #2) in the subsequent care of the patient. For the cherry on top, no one ever performed an actual physical examination on the patient.
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Unnecessary diagnostics. Despite a lack of angina symptoms and normal vitals Troponin and D-dimer were ordered. And guess what the 2nd doctor decided to do when the results were back? To wait 3 hours and take another Troponin. Which is standard procedure if symptom of onset was very recent. However, unbeknownst to them the patient had been having symptoms of episodic tachyarrythmia since 12 hours before admission. Which is plenty of time to allow for Troponin to leak out of the cardiac cell and end in up in the blood - IF there had been cardiac injury.
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Unnecessary treatment. Upon admission the patient received Metoprolol 50 mg, which was a wise decision. For some reason, Paracetamol (Acetaminophen) 1 g IV was administered as well. The patient was in no pain. Had no fever. If you are suspecting a myocardial infarct you would probably give much stronger pain killers than Paracetamol. It seemed like half of the patients in the emergency ward received this medication IV, despite cause of admission.
Conclusion
Any doctor with enough experience knows that a thorough history and clinical examination is the basis of a good diagnosis and assessment. The lack of the these were the reasons for an inadequate medical handling at the Zakho Emergency Teaching Hospital. This is nothing new and is taught in the medical litterature, such as in the preface of Macleod’s Clinical Diagnosis:
Ninety per cent of diagnoses are made from the history.
Clinical examination is the cornerstone of assessment.