THIS CAN HAPPEN PART - II
Dr. Gangadhar Sahoo
Ex- Dean, IMS & SUM Hospital, Bhubaneswar
Ex- Pro VC S “O”A University, Bhubaneswar
President, ISOPARB
Around 25 years back exact date and year I can't remember, I got an emergency call from a nursing home Sambalpur at about 7 pm to attend a post CS case having excess bleeding per vaginum and haematuria (blood in urine). I was staying at Burla around 15 km away from the nursing home. Keeping all my routine work aside, I called my driver and immediately started for Sambalpur. I reached the spot within 30 minutes and immediately rushed to the OT where the patient was shifted for examination. The anaesthesiologist and the owner of the nursing home were present beside the patient. Patient was operated in the morning at 7am under spinal anaesthesia for her 2nd CS. It was an elective CS. Because the doctor was to go on leave he did the operation as per the request of the patient and her husband. After the surgery he had left for his village around 250 km from Sambalpur , handing over the charge of the patient to the anesthesiologist.
Without wasting much time I discussed with the anesthesiologist if there was any intraoperative problem which he replied in negative. I examined the patient. She was in shock, urobag contained around 300 cc of bloody urine and vagina was full with blood clots. I changed the urobag and catheter, cleaned the vagina, started the utrotonics and gave requisition for 3 units of blood. One blood was at hand which I asked to transfuse. I waited there for half an hour to observe the condition of the patient. After half an hour the condition of the patient was as before. Bleeding was continuing. I documented everything in the patient's case sheet and suggested for examination under anesthesia and reopening if necessary. By that it was 9 pm.
I discussed my views with the anaesthesiologist and Dr. Basa, the nursing home owner regarding the reopening of the abdomen and do the needful. The husband and the relatives of the patient were called. I once again explained that the patient is bleeding inside which is not responding to the medical treatment. It is not also possible to know the site of bleeding either by clinical examination or by ultrasound. So reopening is necessary. There are different methods of treatment to stop bleeding which will be decided after opening the abdomen. If everything fails we may have to remove the uterus. The sooner it's done the better. Any delay may result in shock or coagulopathy. The risk to the life of the mother can't be ruled out but it is negligible if done sooner. Blood transfusion will be required. I asked them if they agree then we will proceed to arrange for the surgery. The patient party took time to decide with different pleas. I documented everything in clear terms and took the signature of the husband, another relative, the anaesthesiologist and the nursing home owner. At last they decided to take the patient to the nearest medical college hospital for better treatment. Most probably they had no confidence on me. It's natural. They didn't know me. How can they leave such a critical case under me? I returned home at 11.30 pm asking the anesthesiologist to complete the formalities of referral at the earliest. I assured them that I will request the Gynecologist and anaesthesiologist on duty in the medical college hospital to take maximum care.
I ventilated this information to the senior anesthesiologist and gynecologist on duty regarding the patient. It was 12 midnight and I went to sleep. My body was exhausted but not my mind. I lied down on the bed but could hardly sleep. The picture of the patient was dancing in front of me. I was very much apprehensive and all negative thoughts were clouding my mind. “Did the patient reach on time? Were the surgeon and the anesthesiologist free to take up the case at the earliest? Was blood available in the blood bank? Was the patient stable or had she deteriorated? Had she gone to shock or developed coagulopathy?”
I took a tranquilizer and tried to sleep. But sleep was a dream. Looking to the wall clock time and again did not solve my problem, as it was not moving as fast as I expected. Anxiously waiting for the morning to get the news. Everyone of my family was fast asleep. I was the odd man out. I was cursing myself why I became a doctor!
In this mental turbulence I spent almost five hours. I lost my patience when the wall clock struck 5. All my family members were in deep slumber except my mother who could sense my condition. She was ready with a readymade cup of tea. “What’s the matter? Why are you so tense and disturbed? So early you are going to the hospital, any mishap? “And such a long chain of questions. I said, “Once I return I will tell you everything." Saying this I left.
When I entered the hospital campus I saw the police vehicle parked in front of the Gynecology department and police personnels patrolling on the road in front of the Department. The owner of the Campus Medical Store came out, and stopped me and requested me not to go to the department as the situation was tense following the death of a patient on the OT table last night. The patient’s relatives ransacked the OT and threatened the operating team with dire consequences. At present the police had taken the control of the law and order situation and not allowing anybody to enter into the department campus.
Later I came to know that the patient was received at 12.30 midnight. After completion of all admission procedures and arranging blood and blood products the patient was shifted to OT after around 2 hours. On the OT table the patient was examined in the presence of anaesthesiologist and a surgeon. At that point of time the patient was in shock and bleeding from different sites like vagina, urinary bladder, wound site and from the injection prick sites. When the anesthesiologist put the ryle's tube ( naso gastric tube ) , frank blood came out from the stomach. Patient had developed a dreaded complication called DIC (Disseminated Intra vascular Coagulopathy) , a coagulation disorder resulting in exhaustion of systemic coagulation factors and causing bleeding from different sites. In this situation any surgical procedure is contraindicated unless Coagulopathy is corrected. So the patient's relatives were counseled accordingly. They were categorically explained the prognosis of that deadly complication. The blood bank of the medical college hospital was not equipped with such modern facilities of testing the coagulation profile and supplying the required coagulation factors. Fresh blood transfusions had its own demerits. So it was a helpless situation for the patient. Neither they can take the patient to the best hospital of the state which is around 300 km away nor can they do anything.
Praying was the last effort for Divine help where miracle can happen. But it was not to happen in this particular case. Ultimately the patient succumbed to this complication at around 3.30 am. The patient's relatives blaming the hospital for delay and negligence started all the nuisances which was very much normal. Hospital is a soft target and for doctors it's a professional hazard.
If we analyze impartially, “Could this death have been prevented?”
- Was the decision to do CS correct?
It was an elective operation without any medical or obstetrical indication. Because the treating physician was going on leave, as per the patient's request it was done. Jolly well the treating doctor could have refused.
- Was there any miscommunication which might have lowered the confidence of the patient?
Yes. The treating physician had not introduced any Gynecologist to the patient who could have taken the responsibility during his absence. Thinking that it was a simple and smooth surgery he went out giving the responsibility to the anesthesiologist, might be for monetary benefit.
I always teach my students, “Any surgery is neither easy nor difficult. It's either made easy or made difficult.“ Here the complacency on the part of the treating physician could have been avoided.
The second miscommunication might be the lack of confidence of the patient and her husband on the visiting Gynecologist. The nursing home owner and the anesthesiologist should have built the confidence in the patient that the visiting surgeon was one of the best and most dependable surgeon so that their acceptance could have been better.
- Was the operation delayed and due to whose fault?
The visiting physician had correctly apprehended the complications likely to occur. Had the nursing home owner and the anesthesiologist agreed for repeat surgery and convinced the patient and her husband, the matter could have been solved then and there. What I felt they seriously did not want to take the responsibility. Automatically there was delay in taking a decision and transfer of the patient to the medical college.
The best lesson learned in this episode is, “Try to say NO if you are not in a position to take care of the patient both in intra operative and post operative period.”
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