THIS CAN HAPPEN
Dr. Gangadhar Sahoo
Ex- Dean, IMS & SUM Hospital, Bhubaneswar
Ex- Pro VC S “O”A University, Bhubaneswar
President, ISOPARB
I am writing this anecdote of late 1990s. I was working as associate professor ObGy in VSS Medical College Burla. The final oral and clinical examination of final MBBS students was going on. Professor Snehanjali Senapati and Professor Raseswari Panigrahi were the internal examiners. At around 2pm it was lunch break. All the students and staff had gone for lunch. Snehanjali Madam and Raseswari Madam were climbing down the staircase. There met the attendants of a patient just admitted in the labor room and ventilated their apprehensions and concerns of the new patient to Raseswari Madam. Madam was the most popular doctor in Western Odisha more so in Sambalpur and Burla. Madam listened to their grievances patiently and entrusted me to look after the patient since I was the consultant on that day and she was admitted under me. So I went to the emergency ward in the labor room to examine the patient.
During interrogation I came to know that the patient carrying her second pregnancy of 28 weeks was referred from a private hospital with history of foul smelling watery vaginal discharge for last two days and fever with chill for one day following unrevealed / suspected induced abortion by a private practitioner. Smelling some medicolegal problems the authority of the private hospital referred the case to our medical college. She had a daughter of 2 years old, delivered by Ceaserean Section (CS) . One of her close relatives, very well known to me revealed that she had undergone sex determination. After that she had undergone an invasive procedure for termination of the pregnancy by a local private practitioner. On examination she was stable but toxic with high fever, high pulse rate, dry tongue, 28 weeks size tender uterus and foul-smelling thick purulent vaginal discharge. Our clinical diagnosis was late mid-trimester induced septic abortion. I called the relatives of the patient including her husband, mother and mother in law and counseled them regarding the condition of the patient, line of management including the method of expulsion of the septic product of conception and the dangers / complications likely to be faced. The worst complication in this case is death due to dissemination of septic emboli to heart and lungs resulting in sudden cardiac arrest and death. Even though it is rare it can occur. But from the reaction of the attendants I could sense that they were neither serious about it nor were convinced. Their feeling was that, as a part of the duty of the doctor I was frightening them. Anyway after counseling I got the paper signed by the patient and her relatives. A separate consent form of treatment was signed by the patient and her husband also. Then I discussed with the labor room doctors and staff sisters regarding the investigations to be done which included for the cause of fever and for the intrauterine fetus. If the patient remains stable the procedure of termination will be started at least 24 hours after starting the higher antibiotics. By the time I finished the labor room round it was five minutes to 2 pm. It was the changeover period for doctors and all other staff doing morning duty. I am always afraid of this transit period of half an hour this side and half an hour that side. From my experience I know maximum problems do occur during this period.
After that I left the emergency ward for lunch. Hardly I had reached home I saw two people speedily coming after me with a two wheeler. I stopped at the gate to listen to them. They were trembling, sweating and stammering. I consoled them to calm down and tell what happened. They told, “Sir! The patient you just saw has suddenly become sick following an intravenous injection given by one of the trainees. We can't say whether she is alive or dead. Doctor! Please come.” They returned immediately. I couldn't but rode back to the emergency ward to assess the situation. I couldn't believe my eyes what I saw! The patient was lying still, one PG student doing cardiac massage, sister is busy in running the fluid and the medical attendant testing for flow of nasal oxygen. All were in panic mode. The senior doctor on duty was yet to reach the hospital. A PG student had gone to fetch her from her residence. Two female relatives, who were present, were staring at each other and crying. They could smell something wrong had happened. One of them over phone was giving a running commentary. Within no time 7 to 8 people entered into the room. Anticipating problem I shifted the patient to OT and called the anaesthesiologist. The patient was in shock, pulse rate around 160, feeble only recordable by the monitor, blood pressure was not recordable and oxygen saturation was too low. Immediately the patient was intubated and all antishock measures started. In the mean time I had collected the history that following IV antibiotic suddenly the patient complained of severe chest pain and collapsed. That might be an anaphylaxis reaction or a massive embolism. Whatever might be the cause, the treatment is same and what measures were taken were right. At that point of time the senior resident of the emergency reached the spot and begged excuse for the delay without understanding the repercussions and seriousness of her absence and the damage already caused to the reputation of the hospital. Without discussing anything more with her I just advised her to document everything sequentially with perfection.
The anaesthesiologist was trying hard with all possible permutation and combination to revive the patient but it was a futile exercise. I anticipated that trouble is inevitable once death is declared. So I informed all concerned including the medical superintendent, HOD Gynecology, Anaesthesiology, the Dean and administrative officer. The condition of the sinking patient spread like a wild fire. People from all sections were gathering. Hospital is a soft target for everyone irrespective of the region, religion, caste and political parties. They all were united and shouting slogans against the doctors and hospital authorities. Gradually the rush was so much that it was impossible to control the mob by the handful of hospital security guards. Police was officially called to take care of the law and order situation. Police as usual started playing a dubious role. Instead of maintaining law and order situation they searched the ticket and files not sparing the doctors from questioning and cross questioning as if they were the investigating authority. This action of the police provoked the revolting mob to go on rampage.
Some of the agitators forcibly entered into the hospital building. They started shouting in front of the office where all officials and police were seated, to punish the wrong doers and the negligent staff. They sat on the corridor and refused to take the dead body unless action is being taken. The hospital staff and students also had gathered to counter the agitators. Arguments and counter arguments continued. One of the doctors lost his temper and told, “We have not invited your patient. Have we? You had come here for treatment. Here no intervention was done. We have just started treatment. Your patient suddenly collapsed. It's nobody's fault. We are not God. Don't think that once you are in hospital you are immune to complications and death. Let's do postmortem and the cause will be known. "Hearing this out of anger one of the agitators lifted a table and thrashed it on the floor. It broke into pieces. He held one wooden piece and chased the doctor group to attack. The police was the silent spectator. Sensing an inflammable situation the HOD Gynaecology came out of the office room and asked the doctors to remain silent and calm down.
The closed-door meeting continued inside the office room. At the same time the tempo of the agitators was at the boiling point. Some people were enjoying this situation by adding fuel into fire. Rumor after rumor was cloned and was spreading in lightning speed through the cell phones. A message came that the local MLA was coming with the district collector and SP. This message triggered the volatile situation to be more violent. It was around 11pm. Message came that due to some urgent emergency work the MLA was not able to come. The tired and exhausted agitators were still adamant on their demands. The authorities of the hospital and the police together tried not to prolong the issue to avoid difficulties faced by the innocent patients. They discussed with the aggrieved party and I as the head of the emergency department was given the responsibility to break the news and pacify the mob. I knew it was one of the complications of the disease process which is unpredictable and not preventable. Utilizing all my experience and being calm and composed I explained them in detail what had happened. I assured them full cooperation from our side in any type of investigation whether it's departmental, police or legal. I was not miser in saying sorry for the unprecedented situation which arose out of misunderstanding and sympathizing the great loss to the family and friends of the deceased. From the group of agitators there were many known faces who were helped by me personally. They came forward and demanded a written statement. I did that. Then the volatile, provocative and inflammable situation was brought to under control. The dead body was handed over to the police and the mob gradually dispersed.
To me one aggravating factor which gave rise to this type of unpleasant situation was the absence of the senior doctor on emergency duty. Had she been there, death might not have been avoided but surely such a situation could have been avoided. One thing saved us was the written documentation of counseling before starting the treatment, where I had mentioned the fatal consequences of septic abortion which can occur.
Few take home messages from this mishap:
1. Good management of time: Reach 5 minutes earlier and leave 5 minutes later.
2. Proper counseling before starting treatment.
3. Thorough documentation.
4. Never lose temper. Never be panic. Always be calm and composed.
I wish such incidence should not happen to anybody.
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