Sunday, April 13, 2008

Times I Screwed Up (1)

There are times when good intentions and random acts of kindness are just never enough.

Times I Screwed Up (1)

There are patients whose names I can never remember, even when they greet me on the street. In times like these, I try my best to fake recognition and camaraderie, but my unrehearsed act almost always fails me. Then there are patients that I’ll try my best to forget, but their names and their faces keep on emerging in times they’re least expected.

Nyuk Lan (not her real name) was admitted for a left hip fracture. At a ripe old age of eighty nine years, a trivial fall at home on a dark Sabah dawn was all it took to break her osteoporotic hip bone.

To make things worse, an osteoporotic fracture was just one of Nyuk Lan’s long list of issues. A chronic smoker, she was at an extremely high risk of developing orthostatic pneumonia due to prolonged bed rest. Her blood pressure was also sky high despite repeated measurements. She was most probably an undiagnosed hypertensive for a great number of years. She was mildly anemic, which is not uncommon among elderly folks her age. This is usually due to multiple interacting factors.

I was not the first person to attend to Nyuk Lan. Nyuk Lan only came under my care after her concerned daughter approached me complaining that the elderly lady was having severe dizziness and nausea with abdominal pain.

The first attending doctor had prescribed a combination of pain killers – paracetamol, ibuprofen and tramadol. Strong medications but poor choices for a frail old lady, I thought. Ibuprofen can trigger severe gastritis while tramadol frequently causes dizziness, nausea and vomiting and high blood pressure among ladies. Naturally, I stopped the medications, prescribed other pain killers and gave some reassurance to the patient before moving on.

I took a keen interest in Nyuk Lan’s care since then, to the point of being possessive. Elderly patients are truly fragile, more prone to developing adverse reactions to all medications and usually in greater severity. While in medical school, I had made it a point to read pharmacology as thoroughly as I could, mostly at the expense of other subjects, especially those I truly dislike like obstetrics and gynaecology.

Over the next few days, I gradually took over the daily management of Nyuk Lan, successfully identifying her growing list of issues. Clinical practice very much revolves around the ability to identify possible threats, treating and preventing them in the process.

Nyuk Lan was planned for surgical repair of her hip but her other medical issues need to be optimized before proceeding with operation. Statistics were not on her side. Among elderly folks with osteoporosis, 10 to 25% will die within the first year after a hip fracture regardless whether any surgical intervention was performed. Nyuk Lan had more than just osteoporosis to battle with.

She had underlying chronic lung disease from years of smoking. I made sure she was receiving chest physiotherapy alongside the appropriate medications. She was hypertensive so I stabilized her blood pressure. She was constipated just like many other elderly folks. Mild laxatives eased her discomfort.

Above all, she was still anxious despite much reassurance. She had never been hospitalized before, what more a surgery. The granny requested for some vitamins and supplements to speed up her healing after her impending surgery in a few days’ time. I looked at her charts. She was anemic. I wrote her a common cocktail of supplements - vitamin B complex, folic acid and iron tablets. She was grateful, more at rest, more confident of being able to recover from surgery later. She slept well that night, reportedly for the first time since admission.

I felt good. I slept well too.

The big day came and went. An elderly lady with multiple medical issues had successfully undergone a hip surgery under spinal anaesthesia. Three days after operation, the consultant surgeon saw her fit to be transferred to the ‘extension ward’, located 500m away from the main hospital building. I had my doubts over the wisdom of his decision.

Five nights later, I received a call from the extension ward. Nyuk Lan was in pain and breathless. As I rushed up, the possible lists of diagnoses ran through my mind – a heart attack, inadequate pain relief, pneumonia, pulmonary embolism, exacerbation of her chronic lung disease and so on.

She was indeed in pain, but not too breathless. I ordered an ECG and the relevant blood investigations. The ECG machine was faulty, but from what I could decipher, there were no obvious changes of a heart attack. She was having abdominal pain, she described it something longstanding and not new. I administered some medications for gastritis while awaiting blood results, which will take a while in our retarded healthcare system.

I informed my colleague on-call regarding Nyuk Lan’s condition, reminding her to trace the blood results.

The next morning, Nyuk Lan was transferred back down to the main hospital. Her condition had deteriorated overnight and her blood results were very suspicious of an overwhelming infection. My colleague on-call the night before had conveniently forgotten to trace the blood results. The nurse on duty was incapable of interpreting the grossly abnormal reports and did not inform anyone.

I attended to Nyuk Lan. She was still conscious, but in severe pain. She was severely dehydrated and running a high fever. Her blood was very acidic and her kidneys were failing rapidly. Despite all our resuscitative measures, we knew she was dying and our efforts were in vain. We had missed the boat, the crucial timing when we could still have saved her life.

I guess Nyuk Lan knew too. With whatever strength she had left, she asked me for some ‘vitamins’ to see her through the moment when she’ll breathe her last. I served her the medications myself.

She died later that evening, surrounded by shocked family members.

Cause of death: sepsis of unknown origin.

The next day, her daughter came to the ward to collect the death certificate. She was in grief but well composed. She showed me a photo of her beloved mother taken two years ago and remarked how much weight she had lost since the onset of the chronic abdominal pain and constipation. She thanked me one last time, especially for the moments I was kind enough to giver her late mother the vitamins she requested.


Somehow, it all suddenly came together like a eureka moment. This time however, I was overwhelmed with shock, regret and guilt.

Chronic abdominal pain and constipation in an elderly lady was highly suspicious of underlying colon cancer. The anemia, the poor appetite, the unexplained weight loss – it all seemed to piece together now. Everything fell in place like a completed complicated jig saw puzzle.

Post-operatively, she had required morphine for pain control, which worsened her bowel movement. The night she was in severe pain, she had not passed motion for days and was most likely experiencing subacute intestinal obstruction due to an obstructing tumor in the colon. Protracted intestinal obstruction could have easily resulted in severe sepsis. My vitamins comprised iron tablets, which were notorious for causing constipation.

I was essentially dealing her a death blow. I had killed a patient that I had sincerely wanted to help.

There are times when good intentions and random acts of kindness are just never enough.

I don’t know. Maybe I’m being too harsh on myself. There is no way anyone can prove that Nyuk Lan had underlying colon cancer. There is no means by which anyone can prove that my iron tablets drove the final nail into her coffin.

Who would have thought that iron supplements can kill a patient? Which sensible doctor would have ordered a colonoscopy on a patient with hip fracture? Even if she was found to have an underlying tumor, which surgeon would have operated on an 89-year-old lady with multiple comorbidities?

I can justify myself all I want. It will easily appear sensible and pardonable to most listening ears. It will even stand in a court of law should this case ever become a medicolegal contention.

Still, one knows by intuition when one has erred. They say to err is human and to forgive, divine. Well, my error which can never be proved or disproved has caused the loss of someone’s mother, grandmother and great grandmother.

It could have been my own grandma, and the knowledge of that only adds to the guilt.


CK Tan said...

POTS, I really admired you for what you are writing here. Dun be too hard on yourself. Sabah is such a lucky place to have you as a doctor here.

Jay said...

POTS, I think you're being too hard on yourself. Mild anemia and constipation are extremely common in this age group. A PR exam is mandatory but the fracture should have been fixed before any further investigation, anyway (provided the history and radiographs didn't suggest a pathological fracture). Iron constipates but I have yet to see intestinal obstruction because of iron supplements alone. She deteriorated from post-op sepsis which has a plethora of causes in a someone with so many co-morbidities. The tragedy is that she was allowed to reach the stage of multi-organ dysfunction before intervention. That wasn't yr fault, I imagine.

Anonymous said...


"For the resolutions of the just depend rather on the grace of God than on their own wisdom; and in Him they always put their trust, whatever they take in hand.
FOR MAN PROPOSES, BUT GOD DISPOSES; neither is the way of man in his own hands".

Major things in life such as births and deaths are preordained. Sounds fatalistic or worse hackneyed but hey it’s a time worn axiom that is as old as the hills.

You care! This is why Nyuk Lan’s demise has a profound impact on you. She may be etched indelibly in your memory but from your account of the events leading to her demise no one can fault you on the course of action you elected.

All you have is a niggling suspicion. Nothing conclusive. For all you know there is no connection whatsoever between the ‘vitamins’ and her demise. You don’t know exactly (and never will) what precipitated her death. You can only conjecture.

It was perhaps an unfortunate conjunction of circumstances, a combination of factors culminating in her demise. After all there is no denying that the odds were stacked heavily against her (a patient in her dotage with all sorts of ailments).

In retrospect and with clarity of thoughts, however ill advised prescribing ‘vitamins’ was, you acquiesced on account of her request. A solicitous doctor ever mindful of a patient’s comfort and well-being.

In any case it’s fait accompli so it’s pointless and unproductive to cudgel your brains trying to second guess yourself, replaying the sequence of events ad-nauseam like a broken record stuck in the same groove unless you’re a glutton for punishment. Doing that is akin to flogging a dead horse.

As far as one can tell, your conduct was exemplary. There’s nary a doubt in the minds of the readers of this blog that you did right by her. You have been nothing but professional. You said it yourself, your actions were exculpatory and no opprobrium will be attached to one who has been nothing but scrupulously meticulous and thorough.

I can justify myself all I want. It will easily appear sensible and pardonable to most listening ears. It will even stand in a court of law should this case ever become a medicolegal contention.

It’s also reassuring to have doctors with uncompromising standards who reflect and ruminate, dissect and analyse.

Q8-) Reassured kindred spirit

Lately there has been a paradigm shift in the treatment of patients. This trend toward a more holistic approach is long overdue and much welcomed.

zewt said...

it may be a lil bit morbid reading your article sometimes but it serves as perfect reminders that we are all fragile being.

i seriously need to go see an ENT soon...

sojourner said...

POTS aka owner of 'fat boy', i guess everytime a patient dies under our care, our first reaction is to blame ourselves for not doing/knowing/caring/bothering enough. but life and death is really something beyond our control. and i know you do/know/care/bother enough. and the poor old lady knew that. we'll never know if your hypothesis is right. but perhaps she'll be one of the 5 people you meet in heaven. when you see her, she'll unravel all the mystery surrounding her death. keep caring! God bless....